Anastomotic Insufficiency (in elective colon resection 1-3%)
Anastomotic insufficiency represents the most severe complication after colon cancer resections. Any deviation from the normal postoperative course should suggest anastomotic insufficiency. In case of justified suspicion, an immediate endoscopy (flexible) and/or a CT with rectal filling should be performed.
Clinically evident usually between the 5th and 12th postoperative day.
A low CRP (C-reactive protein) between the 3rd and 5th postoperative day has a negative predictive value; values > 170 are suspicious in the corresponding clinical context.
Prevention through: tension-free approximation of well-perfused bowel ends; restrictive perioperative intravenous fluid administration.
Treatment: Revision surgery. Reestablishment of the anastomosis with or without stoma formation depending on intraoperative findings and the patient's condition. In septic conditions -> discontinuity resection.
Wound Infection (4->30% depending on definition, diagnostics, and follow-up time)
According to CDC (Center for Disease Control), 3 categories are distinguished:
- A1 superficial infections involving only the skin and subcutaneous tissue.
- A2 deep infections reaching down to fascia and muscles.
- A3 infections with organ involvement
Prophylaxis: Administration of antibiotics up to 30 minutes before skin incision and repetition after 4 hours for corresponding surgery time and continuation in contaminated wounds; first dressing change 48 hours after surgery; avoidance of hypothermia.
Treatment: Wide opening of the wound, regular rinsing with sterile saline solution; if necessary, calculated antibiotic therapy effective against E. coli and S. aureus, the two most common pathogens of wound infections. Debridement of necrotic areas. Large wounds with pocket formation may be suitable for vacuum therapy.
Abscess (0.7-12%)
Symptoms: Intestinal paralysis, localized peritonitis, signs of inflammation (leukocytosis, fever, high CRP)
Diagnostics/Treatment: Ultrasound or CT possibly with interventional drainage placement. Smaller abscesses without clinical signs of infection, diagnosed incidentally, should be monitored over time and do not necessarily require surgical or interventional treatment.
Abscess formations near the anastomosis indicate anastomotic insufficiency. Therefore, when intra-abdominal abscesses are detected, an anastomotic leak must be ruled out. If contrast medium enters the abscess cavity and then into the bowel, an anastomotic insufficiency is confirmed.
Prevention through peritoneal lavage, which not only reduces bacterial contamination but also removes blood and clots as a breeding ground for pathogens. Proinflammatory cytokines, which are precursors of adhesions, are also greatly diluted by lavage.
Burst Abdomen (early postoperative fascial dehiscence) (Incidence up to 3%)
Usually a result of postoperative wound healing disorder, other influencing factors include patient-related comorbidities and the surgical technique of abdominal wall closure.
Between the 8th and 12th postoperative day, often initially as a subcutaneous burst abdomen with intact skin closure.
Symptoms: Progressive serous secretion from the wound or subileus complaints.
Treatment: Immediate surgical intervention always with revision of the abdominal cavity to exclude an intra-abdominal cause. Closure of the abdominal wall with or without vacuum dressing, in complex infection situations open wound treatment as laparostoma.
Postoperative Ileus (up to 20%)
Symptoms: Nausea and vomiting, inability to take oral intake, distended abdomen, sparse bowel peristalsis.
Treatment: In case of recurrent vomiting, insertion of a nasogastric tube for decompression of the gastrointestinal tract and aspiration prophylaxis.
7 days after inadequate food intake, parenteral caloric supply with 25-30 kcal/kg body weight (Protein:Fat:Carbohydrates – 20:30:50) should be started.
Prophylaxis: Restrictive intravenous fluid administration, epidural anesthesia.
Postoperative Hemorrhage (0.5-3%)
Causes: Coagulation disorders or technical errors directly related to the surgery.
Symptoms: Tachycardia, hypotension, oliguria, blood in the drainage
Diagnostics: Laboratory hemoglobin and hematocrit drop; ultrasound, CT with angiography.
Treatment: In case of circulatory instability, immediate surgical re-exploration. In circulatory stable patients, precise localization of the bleeding source (intra- versus extraluminal), optimization of the coagulation situation.
Intraluminal bleeding is initially treated endoscopically, in case of problems possibly angiography and superselective embolization.
Anastomotic Stricture
Initially, endoscopic dilation attempt, if unsuccessful, surgical reestablishment is unavoidable.
Incisional Hernia
Surgical treatment at the earliest after 6 months with mesh repair.
Other Complications:
Intraoperatively overlooked Bowel Injury. Often insidious course, noticeable drainage secretion, high inflammatory values, contrast medium leakage in radiological diagnostics. Prevention through complete inspection of the bowel, especially after extensive adhesiolysis before abdominal wall closure.
Intraoperatively overlooked Ureteral Injury: Abdominal or flank pain. Abundant "clear" fluid discharge through the drainage(s) with simultaneously reduced urine output. Diagnosis by creatinine determination from the drainage secretion. In case of ureteral obstruction by ligatures, clips, or scar stricture, a urinary obstruction develops. Further invasive urological diagnostics with retrograde ureteral imaging.
Medical Complications: Thrombosis/Embolism; Pneumonia; Cardiac Complications; Urinary Tract Infection; Stroke
