This is a topic no one likes to talk about, but it is a reality that you must understand before you have surgery. Current legal thinking is that the risks and benefits of surgery must be explained to you before you can give informed consent and agree to have an operation. In theory, this is a good idea, since no one in his or her right mind would agree to an operation with a 100% complication rate. Beyond that, it is important that you know what could possibly happen to your body after your operation. In reality, there are so many possible extremely infrequent complications that could occur that to detail each one would not be possible. In practice, most surgeons will list for you the most frequent complications specific to your operation. This is an attempt to provide you with information without scaring you out of a needed operation. In my opinion, it is not possible for you to give a truly “informed consent” unless you have studied surgery for years. That is not to say that surgeons are more intelligent than their patients, my point is simply that there are so many potential pitfalls to even the most minor procedure that to understand the risks you must have witnessed a tremendously large number of operations. The goal of this chapter is not to frighten you. It is to raise you level of awareness to possible outcomes so that you go into the operation with your “eyes open.”
Complications may be divided into 2 general categories: major and minor. Examples of minor complications include localized wound infections, urinary tract infections, and phlebitis at the site of an intravenous line. You may also experience minor bleeding or bruising at the wound site. Most of these complications can be corrected with rapid and appropriate treatment. In almost all cases, they do not alter the length of your hospitalization. Major complications include failure of the operation, heart attack, stroke, major bleeding, blood clots in the legs (or rarely, the arms), overwhelming infection, pneumonia, and death. Unfortunately, any of these complications can occur after even the simplest operation. Careful preoperative screening and vigilant postoperative care can minimize the risk of these complications; but even under the best of circumstances, they can occur.
If you carefully follow the advice given in Chapter 5, I believe you will be well on your way to avoiding complications. Of course, even if you follow my suggestions to the letter, you will not eliminate the risk of complications. Below we will consider several complications and their treatments; so if you do run into one of them, you will understand what is being done to remedy the situation.
Failure of the Operation
This is rare but not impossible. There are numerous reasons that operations cannot be completed, and it is not possible to discuss them all here. Suffice it to say that all operations are performed under a certain set of assumptions, many of which cannot be verified before your operation. If your surgeon finds that the criteria for safely completing the operation are not met, the operation will not proceed. Alternatively, you surgeon may find that a different operation would better suit the circumstances encountered; and you may wake to find you had a procedure that you had not discussed. In a worst case scenario, it could be discovered that your disease is not repairable by surgery; and you will leave the operating room with both an incision and your original disease.
Every operation, no matter how small, runs the risk of significant blood loss. Typically, this can be well controlled in the operating room, but you may require a blood transfusion to prevent anemia (low red blood cell count). To minimize bleeding, you should avoid products that inhibit platelet function as discussed in Chapter 5. Additionally, if you bruise easily or have a relative who has experienced major blood loss from a minor injury or surgery, you should let your surgeon know. You may need additional screening tests before the start of your operation. Having done your part, it is now up to your surgeon to be as careful and thorough as possible to prevent unnecessary bleeding, and to control any bleeding necessary for the procedure (for example, the careful division of arteries supplying a tumor). It is never possible to control all points of bleeding at surgery; and in almost all cases, some minor bleeding occurs. Your clotting system will take care of this trivial blood loss; and with time, the injured blood vessels will heal and the situation will return to normal.
Part of the art of surgery is knowing which bleeding will stop on its own and which bleeding needs to be stopped by mechanical (surgical) means. This usually becomes an issue if a bleeding problem is suspected after the operation has concluded and you are in the recovery room or a hospital room (if you are having outpatient surgery, this can happen at home). Many means exist to monitor ongoing blood loss, but the most commonly used are monitoring the vital signs and urine output. If these parameters suggest bleeding, a blood count may be drawn to determine if you have lost (or are losing) more blood than expected. If you are, your surgeon will either elect to give you a transfusion and follow the situation closely, or possibly return to the operating room for another look.
Once the bleeding is controlled, you may need additional transfusions of blood or blood products (platelets or liquid clotting factors). Fortunately, after the problem is corrected, you should have no further problems. In circumstances in which blood transfusions are required, there is a risk of contracting certain blood borne viruses (such as Hepatitis or HIV), since these can be passed from blood or blood products. Remember, however, that the blood products available in the United States today are rigorously tested and are extremely safe. Your risk of contracting a disease from a blood transfusion is lower today than it ever has been, and with continued advances in molecular biology, I imagine the blood supply will become only safer over time.
The surgical attachment of two tubular structures (such as blood vessels or pieces of bowel) is called an anastomosis. To make these attachments, the two structures are brought together in the proper alignment, then sutured or stapled together. When this is completed, the anastomosis is inspected, but as you can imagine, it is rarely (if ever) fully watertight. In the case of blood vessels, a localized clotting process will occur at the anastigmatic site, and this will effectively create a seal around the connection point. In the case of the bowel (or any other structure that may be connected, including airways, nerves, ureters, gynecologic or reproductive organs.), there is no biologic glue to seal the anastomosis; so we depend upon the suture or staples to hold the tissue together until wound healing occurs in a week or so. It is believed that all of these anastomoses leak to some degree, but that a small amount of leakage is handled by the body. In some instances, the leakage overwhelms the body’s ability to handle it, and a problem occurs. Often surgeons will leave drains in areas that they think may leak, thus enhancing the body’s own defenses. Where there is no drain and a significant leak occurs, a collection of fluid will develop. Depending upon the content of this fluid, the fluid collection may represent a simple nuisance or a full-fledged emergency. Since there are so many different types of anastomosis, it is not possible to discuss the solution to each one. Suffice it to say that clinically significant anastomotic leaks of any type tend to require further surgery unless the area around the leakage is well drained. An exception to this is a vascular anastomosis, where a significant leak will almost always require a surgical repair.
A dehiscence is basically the failure of a suture line to hold together. There are many causes for dehiscence, and some patients are at higher risk for this complication than others are. If the dehiscence occurs weeks or months after the operation, this tends to result in the formation of a hernia at the incision site. Depending upon the size and symptoms associated with this event, your surgeon may recommend simply observing the hernia over time or suggest a surgical repair. If the dehiscence occurs soon after surgery (days to weeks), this can become more of a problem. If you experience the sound or sensation of a “pop” from your incision, and this is followed by drainage of fluid from your suture line, you should inform the hospital staff or your surgeon immediately. There are several treatment options, but in many cases you will require a return trip to the operating room to repair the original closure.
Deep Venous Thrombosis (DVT)
A deep venous thrombosis is the development of a blood clot in the deep veins of an extremity, typically the leg. This occurs for several reasons, but suffice it to say that many disease states increase the likelihood of developing blood clots. Add to this the tendency for increased blood clotting after surgery and you can see that surgical patients are at high risk for this occurrence. The final piece of the puzzle is the pooling of blood that results from inactivity. Now you can see why surgeons are so insistent that their patients be up and about as soon as possible after an operation.
Even under ideal conditions and with all the appropriate preventative measures being taken, a certain number of patients will develop this complication. Once formed, these clots have the ability to break off and travel to other parts of the body, possibly resulting in pulmonary embolism or stroke. For this reason, if you develop a deep venous thrombosis, you will be placed on blood thinner to try to prevent the clot from spreading or enlarging. You will probably be discharged from the hospital on a blood thinner and will be required to stay on this therapy for 6 months to a year. If you cannot safely take a blood thinner, or if you are given a blood thinner and still develop complications from this clot, you will need to have a filter placed in your vena cava (the largest vien in the body, which leads to your heart). This filter is designed to catch any blood clots that break off and begin to travel in your venous system. My advice to you again is to do your part in preventing the development of DVTs by getting up and out of bed as soon as possible after your operation. A short period of discomfort postoperatively is definitely worth it if you can avoid a year of anticoagulation therapy.
Pulmonary Embolism (PE)
PE is one of the most dreaded complications after surgery, which can range from a clinically undetectable syndrome to an immediately fatal condition. In most cases, PE is heralded by shortness of breath, chest pain, and an inability to get enough oxygen into the blood. If you are suspected of having a PE, you will immediately be placed on blood thinner and one of several tests will be ordered to confirm the diagnosis. If you are found to have a PE, several options are available. If you remain in stable condition, the blood thinner alone may be sufficient therapy. If your condition deteriorates, it may become necessary for a drug to be administered that actively dissolves blood clots. This is a dangerous therapy and reserved for only the sickest of patients; in fact, many surgical patients cannot take this drug at all since they would be at risk of bleeding at the operative site. In a worst case situation, you may require a procedure designed to suck the blood clot out of the lung with a vacuum device, or you may even require emergency surgery. Clearly again, the best way to treat a PE is prevention. By avoiding DVTs as described above and in Chapter 5, you will markedly reduce the likelihood of developing this potentially lethal situation.
Cerebrovascular Accidents (CVA or stroke)
Strokes are another possible complication of surgery. As noted above, blood clots are more likely to occur in people after surgery, and a stroke is a blood clot in one of the vessels supplying the brain. The best way to avoid this complication is by careful screening preoperatively. Even with the best of screening, some people will still have strokes during or after their operations. Currently there are not many good options for treating strokes. A blood thinner can be administered to prevent the clot from enlarging, and in some cases a drug may be administered to break up the blood clot (again, not often possible in the postoperative state). Numerous tests will be ordered to determine the cause of the stroke; and if one is determined, an operation may be required. Unfortunately, most times no single cause of the stroke can be determined, and we are left treating the deficit caused by the stroke. On a positive note, with therapy and watchful waiting, most people who suffer strokes are able to return to a productive life.
Myocardial Infarction (MI or heart attack)
As noted previously, additional strain is placed on the heart by surgery. This is a well-known fact, and as such, care is taken before an operation to determine the overall condition of the heart. Unfortunately, heart attacks can occur “out of the blue,” and no amount of testing will eliminate this risk from surgery. Surgeons and anesthesiologists continue to do everything possible to minimize the stress caused by surgery, but as nearly all patients develop coronary artery disease with age, this will continue to be a problem. If a heart attack is suspected, aspirin and blood thinner will be administered, as will supplemental oxygen. All causes of stress will be minimized, and if possible, a blot clot-breaking drug will be administered. Small heart attacks that occur in the hospital can be well treated, and are usually not life threatening. Larger heart attacks may require emergency cardiac catheterization or open heart surgery, and in many cases these still prove to be fatal.
Anesthesia Complications and Death
The process of administering anesthesia itself can cause complications and death. The preoperative anesthesia screening process and careful choice of anesthesia technique coupled with careful intraoperative monitoring has lowered the risks of anesthesia tremendously. Even so, these unpredictable complications still occur, and can have fatal consequences. Fortunately these events are rare; but when they occur, they are devastating to families and physicians alike.
Surgery not only places a tremendous burden on the heart but also puts the kidneys at risk as well. The kidneys are very sensitive to factors such as blood pressure and blood volume, two factors that can vary tremendously during an operation. They also receive a high volume of blood flow, and small showers of blood clots can be swept into the kidneys and cause damage. As such, surgeons are very careful to follow the renal function of their patients postoperatively. In addition, several important drugs have the side effect of causing kidney damage, including several antibiotics, as well as intravenous contrast material. Fortunately, with appropriate care, most cases of renal failure will resolve in time, and it is rare that patients require dialysis. If necessary, dialysis will be instituted, and in some cases may become a lifelong necessity.
Another common complication following surgery, pneumonia can range from a highly treatable problem to a lethal one. There are multiple preventative strategies outlined in Chapter 5 for the prevention of pneumonia. If pneumonia develops, often the administration of antibiotics in combination with the mobilization of secretions by respiratory therapy can solve the problem. If the pneumonia is severe, or if the patient has a tenuous pulmonary status to begin with, mechanical ventilation is sometimes necessary to maintain blood oxygenation while the pneumonia resolves. This obviously requires a trip to the intensive care unit and is a serious complication. A variant of pneumonia that occurs when a patient inhales gastric juices will be described below.
The inhalation of stomach contents into the lungs is known as aspiration. For many reasons -- including positioning, depressed mental status due to narcotics and sedatives, and poor gastric emptying due to ileus. -- this is a common complication after surgery. The treatment for this is the removal of the inhaled material through suctioning or bronchoscopy; however, even with immediate treatment, there is a high likelihood of developing pneumonia. Aspiration pneumonia is somewhat more difficult to treat than regular infectious pneumonia because the acid in gastric juice can damage lung tissue itself. Many patients who have an aspiration event require prolonged mechanical ventilation and ICU care. This is one of the reasons surgeons leave nasogastric tubes in place until they are sure that bowel function has returned. It prevents the accumulation of fluid in the stomach and reduces the likelihood of an aspiration event.
Sepsis/Multiple Organ Dysfunction Syndrome (MODS)/Systemic Inflammatory Response Syndrome (SIRS)
A poorly understood but devastating complication of surgery, sepsis syndrome (also known as MODS or SIRS) results from an overactive immune response. This triggers a cascade of inflammatory events in which the body produces a series of compounds that eventually serve to injure itself. Although the subject of intensive laboratory investigation, there is still not an accepted treatment for this process. The best we can offer currently is supportive care in an ICU until the process resolves. This frequently leads to long hospitalizations with multiple subsequent complications, operations, and procedures. Unfortunately, just half of the patients who develop sepsis syndrome will recover and only after prolonged and intensive therapy. Frequently, patients with sepsis syndrome will require the placement of a tracheostomy and feeding tube for support while the disease process resolves.
Acute Respiratory Distress Syndrome (ARDS)
ARDS is a process similar to the one described above in which the inflammatory response is limited to the lungs. This too requires mechanical ventilation and ICU care and also carries a high rate of complications and mortality. In a well-staffed and equipped ICU, patients have a better than 50% chance of survival. Frequently, patients with ARDS will require the placement of a tracheostomy and feeding tube for support while the disease process resolves.
Urinary Tract Infections
Urinary tract infections are a common complication, particularly in patients who have a urinary (Foley) catheter. It has been estimated that you have a 10% per day risk of infection while a Foley catheter is in place. Fortunately, this is usually an easy complication to treat, and the removal of the catheter combined with antibiotic administration alleviates the problem. In rare instances, urinary tract infections can spread to the kidney or to the bloodstream; and in these cases, it may be harder to eradicate the infection. As with most complications, prevention is the best cure. This is why most surgeons will remove the Foley catheter as soon as it is safe to do so. Remember that a catheter is not a means to avoid trips to the bathroom or a way to prevent incontinence. If you don’t absolutely need one, you should not have one.
Depending upon the type of operation and the circumstances surrounding the surgery (i.e., emergency vs. elective, bowel prep vs. unpreped bowel), the incidence of postoperative wound infection can range from 1 to 40%. In its most mild form, a wound infection can be treated with simple antibiotic administration. If this fails to resolve the problem or if a fluid collection beneath the wound becomes infected, you may need to have the entire incision “opened” to allow the infection to drain. This is often described as “allowing the wound to heal from inside out.” If your wound does require wide drainage, you will probably require the assistance of a visiting nurse after discharge, as it can be a labor-intensive process to keep the wound clean. Fortunately, wounds that heal this way are cosmetically acceptable; and once healed (weeks to months later), it will look almost identical to a wound closed with stitches.
Depending upon the cause of the wound infection, a more serious problem may be brewing. Infections of deep tissue spaces and tissue cavities are known as abscesses. An abscess is a collection of fluid that becomes infected, requiring open or closed (percutaneous) drainage. This serious complication may require weeks or months of therapy before it can be resolved. If you develop and abscess and it is drained well, once it resolves, the problem will be solved. On occasion, abscesses will reform or multiple small abscesses will slowly enlarge at their own pace, so it seems like every time one abscess is cured, another surfaces. The key to treating this complication is patience and persistence. Although you may ultimately require a second, third, or even fourth operation, in almost all cases, a diligent surgeon will be able to solve the problem in time.
Drug allergies can range from simple skin rashes to full-blown anaphylactic shock and death. For this reason, you will be asked by virtually everyone you meet in the hospital if you have ever had an allergic reaction to a medication. This is in contrast to a side effect of a medication, which is a predictable adverse effect caused by a drug. Examples of side effects are nausea or forgetfulness, caused by narcotics, or leg swelling, caused by ACE inhibitors. Allergic reactions are not caused by the drug itself but rather by your body’s immune response against the drug. If you have had an allergic reaction to a drug before, you should avoid taking the drug again in the future, particularly if the reaction was severe. You may also develop an allergic reaction to a drug that is similar in structure to the one causing the initial reaction. Finally, even if you have never had an allergic reaction to a medication in your life, you may develop a new allergy while you are hospitalized. It is, therefore, important to let your health care team know if you develop any of the symptoms of an allergic reaction, especially immediately after the administration of a medication. These symptoms include a skin rash, hives, itching, chills, sweats, or lightheadedness. The treatment for most allergic reactions is to simply discontinue the administration of the drug. If the reaction is not severe, your doctor may instead choose to treat you with a medication to inhibit the allergic reaction and continue to use the offending drug.
This poorly understood condition occurs typically in elderly patients, especially those in poor health prior to their operation. Medically, sundowning is a form of delirium, in which patients lose their grasp on reality. As the name implies, this condition worsens in the evenings, for reasons that are still unclear. It is characterized by disorientation (loss of person, place, and/or time), agitation, hallucinations, and paranoid fantasies. Sundowning patients frequently complain that they are being held against their will or tortured. If this should occur to you or a loved one, your surgeon will order a series of tests to ensure that there is no medical condition causing this state of delirium. If none is found, the only treatment is to avoid medications that have a clouding effect on the central nervous system (such as narcotics and sedatives) and to protect the patient from self-inflicted injury until the confusion resolves. This may include the use of wrist, ankle, and body restraints. Although frightening to witness, it is usually a harmless condition if the patient is closely monitored, and it is comforting to know that most patients do not remember anything about the period of their hospitalization when this occurs.
As I mentioned in earlier chapters, this is an extremely serious complication which continues to carry a substantial mortality, even in this day and age. If you have, or suspect you may have a physical dependence on alcohol, you should address this problem prior to surgery. For safety’s sake, if you drink even a single alcohol-containing beverage a day, you should discontinue this practice several weeks in advance of your surgery. If you are unfortunate enough to develop alcohol withdrawal, expect that it will add several days or more to your hospitalization. The most commonly used treatment today is sedation, with a slow weaning of the sedation over the span of days to weeks. In its most severe form, treatment includes mechanical ventilation, ICU treatment, and medically induced coma and paralysis until the withdrawal process is complete.
Should you develop a serious complication, particularly one which requires a transfer to the intensive care unit, there are many common procedures that you may have to undergo in the course of your therapy. The first we will consider is intubation. This is a process whereby a plastic tube is inserted through your vocal chords and into your trachea (windpipe). This may be done for several reasons, all of which ultimately will require the use of mechanical ventilation. This does not imply a lifelong dependence upon a breathing machine. In fact, most intubations are transient events to allow for the optimal treatment of curable problems. If you continue to require the support of a ventilator for more than a week, your surgeon may recommend the placement of a tracheostomy tube. This is essentially a small incision in the neck to allow the placement of a plastic breathing tube directly into the trachea. There are a number of good reasons that this is done, including protection of the vocal chords and trachea. It is also easier to wean patients from mechanical ventilation when they have a tracheostomy. I have found that many patients are extremely fearful of tracheostomy placement, and I am not sure why this operation has developed such a stigma. In reality, when tracheostomies are no longer required, the plastic tubing is removed from the incision site, and gradually the wound shrinks in size until it is fully healed. If your surgeon recommends a tracheostomy, it is a good idea to heed that suggestion.
Nutrition is another important aspect of post-surgical care and is essential for proper wound healing. Those patients who develop serious complications often are unable to eat enough to maintain adequate nutrition. For this reason, feeding tubes are often required. This allows for direct access to the stomach or small bowel, and enables your physician to deliver enough protein, minerals, and nutrients to meet your body’s daily requirements. There are several ways to place feeding tubes, but one of the most commonly used today is the endoscope. Using direct visual guidance, a feeding tube can be placed in the stomach or small intestine at the patient’s bedside in a matter of 10 to 20 minutes. The procedure is virtually painless, and like a tracheostomy, a feeding tube can be removed when no longer needed.
Despite the best efforts of surgeons, anesthesiologists, nurses, and allied health personnel, complications during and after surgery continue to occur. To do your part in preventing complications, follow your surgeon’s advice, as well as the tips outlined in Chapter 5. Remember, the quicker you get out of the hospital, the less likely you are to suffer a complication. That alone should motivate you to get up and get going as soon as possible after surgery. If you do develop a complication, remember that patience is your most important ally. When a three-day hospital stay turns into a month-long hospitalization, it is easy to get angry, upset, or frustrated. Remaining calm and trying to keep a positive attitude will go a long way toward helping your health care team help you to get better. Years after the experience, you will remember that your operation allowed you the joy of continued life free of disease, and you will forget the seemingly endless days of boredom in the hospital.