Immediate Postoperative Complications

There are two immediate postoperative complications for which patients may need to be emergently taken back to the operating room: bleeding and leak

 Bleeding. In the immediate postoperative period, if a patient becomes tachycardic with a drop in the hemoglobin/hematocrit and sanginous fluid inside the drain, this is usually indicative of bleeding from the staple line.Most of the time,this is self-limited and responds to transfusion. However, if the patient continues to bleed and the drain keeps filling with blood, the surgeon should have a set point to take the patient back. In our experience, if the patient’s hemoglobin drops below 8.5, or the hematocrit drops below 25 regardless of the vital signs, the patient should be taken back emergently to the operating room.

The abdomen is insufflated with a Veress needle. The same trocar incisions can be used, with the supraumbilical incision generally used to enter the abdomen. A large amount of clot may be seen around the bleeding area without any evidence of the bleeding vessel. Two other trocars are placed in a triangular fashion. The first step is to suck all the clots with a 10-mm suction catheter to clean the area. Introduction of a raytek can help accomplish this task. After the clots are removed, the area is thoroughly examined to find the bleeder, which will be clipped. After meticulous examination, the raytek is removed and another drain is placed. The application of fibrin sealant on all of the staple lines completes the procedure (Fig. 14.32).

Occasionally the bleeding is intraluminal. Intraoperative endoscopy will reveal if the bleeding is on the pouch side or the remnant side. If it is in the pouch, it can be controlled with endoscopic coagulation; however, if there is no blood inside the pouch, the source of bleeding must be the remnant. The solution is to oversew the staple line with a running suture.

 Leak. In contrast to nonobese patients, tachycardia is the first and sometimes the only sign of a leak in obese patients. Any tachycardia above 100 beats/min is concerning and needs to be worked up. Our first step in work up is a stat CT scan with IV and oral contrast. In our experience, gastrographin swallow is not as sensitive as CT scan in detecting leaks, and the other benefit of CT scan is that it will detect other causes for tachycardia (i.e., fluid collections such as hematoma or rarely an abscess). Small leaks in stable patients can usually be managed with percutaneous drainage, antibiotics, and by keeping the patient NPO. Also, it may be possible to use intraluminal covered stents to traverse the leak. However, patients who become septic or rapidly fail nonoperative management need to be taken back promptly to the operating room.

After insufflation of the abdomen and placing the trocars in a triangular fashion, the area of leak is examined. If the leak is at the jejunojejunostomy, placement of extra sutures with an omental patch will often suffice. Otherwise, the anastomosis should be re-done. A leak at the gastrojejunostomy is usually not amenable to repair with suture due to severe inflammation from gastric secretions. Leak from this area is controlled with an omental patch and extensive drainage with multiple drains. Again, intraluminal stents maybe helpful if the leak is at the angle of His .