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Good afternoon. My name is Kat Bar Room. I'm a colorectal surgeon at the Queen's Medical Center in Nottingham. I'm really sorry, I can't be with you um, this afternoon, but I've got 20 minutes to talk to you all about post operative complications. I think it's really important to remember that any complications possible. Lots of us have seen some slightly odd things post operatively, but actually the common things happen more commonly and that's what we really want people to be able to pick up and recognize and manage are the common post operative complications from the simple things like wound infections to the, you know, more um significant problems that we can see post operatively like anastomotic leaks recognition um does get more of complications, does get more easy with experience. But I think even at S H O grades, you've got several years of clinical experience behind you and you're getting used to knowing what a normal post operative pathway looks like and what patient's who are suffering from a complication might look like when they don't follow that normal postoperative course. Okay. I think the nurses have a really have a wealth of experience if if anyone's, I'm sure about whether they think they're patient's following a normal prospective course or a variation or normal versus somebody who's more unwell. Then I'd recommend that they ask their senior nursing staff to see what they thought about the patient. I've definitely done that in my time. It's about being aware of that gut feeling, thinking something's not right. Something doesn't sit comfortably with me about that patient. They're not quite behaving the way I'd expect them to clinically. I think that's something just to be really aware of that feeling. When you, when you get that and to act on that, it may be that actually you can rule out any complications and the patient's doing fine. But I think it's important to listen to that gut feeling of something may not be quite right. What I want my shh and registrars to do if they find a patient on the wall to the post operative complications, provide some really good first aid. It's really important to go and review patient's face to face. I know it sounds um simple um and obvious, but we're, we have previously seen patient's who have written in the notes. Um The F one is called the Night Team and they've given some advice over the telephone often because they're really busy, but there's nothing really in the beats are face to face. Review. The rest of the first aid package includes things like the Septic Six Management Plans. ABC. Resuscitation things that, you know, um with your eyes closed really, but making sure that they're done properly and completely, it's really important. Um Then thinking about an investigation plan, obviously, speaking to your seniors about any patience you're worried about. I think one of the easiest ways to think about what complications may have occurred are to have a look at the consent form and also the preoperative letters. If I've got a patient that I'm particularly worried about something preoperatively, if there are high risk of a league or if they're high risk of a damage to, to another structure within the abdomen during the operation, I will obviously have spoken to them about that during the preoperative counseling with in clinic and then I will have written it on the consent form. So it's important to be aware of the things that the surgeons are concerned about. And also with the operation note, is this an operation that took five hours and they were head down with their legs and the syrups the whole time. Are they therefore more likely to have a compartment syndrome in their leg or something slightly unusual like that? Um Did they have to over? So any ensure arteries as a small bowel, um could a leak from one of those small bowel and trust me repairs be part of the reason why the patient's not well postoperatively. So look at the consent for all, have a look at the pre operative notes and have a look at the operation and see what's more likely to be causing your problem in your post operative patient and then escalate, speak to the on call team or the patient's own consultant depending on how your your hospital is structured. If patient, if they're pretty surgeons, not on call and not in hospital at the time and speak to the on call team. Some surgeons want to know everything about the patient's recovery. Some surgeons reasonably want to have some time off on the weekends so I speak to the on call team about that like I said before, almost anything um can present as a postoperative complication but the common things and given I've only got 20 minutes, I mean, you're gonna mention a few of these um tend to be things like pain, which arguably is part of the normal postoperative process but can be um can be a significant problem for patient's infections are really common. Wound infections need opening and wounds are likely to infect it should be closer clips so that they can be opened. Um sequentially as they need to if a wound infection develops uh infections in the within the abdomen, in the chest, around venous access lines are also relatively common. Uh Al asthmatic leak is a worry for all colorectal surgeons, not as common as other complications, but it's obviously a significant problem if it does occur and problems with stoners such as high output or no output and stoner viability um are seen post operatively in colorectal patient's and they're gonna be mentioned in the talk otherwise in this session, so I won't dwell on those areas is a really common co postoperative problem. Electoral abnormalities, especially sodium potassium derangements in the emergency setting. Uh delirium in LD patient's an exacerbation of no medical problems can be a concern less commonly, I think are things like bleeding damage to other structures, especially ones that aren't noticed intra operatively, they can occur. But that is unusual. Um And although we always quote for cardio respiratory complications on our consent form, actually instances peeing DVT um relatively unusual complete room dehiscence again also does occur but isn't as common as um some more superficial wound infections. I'm going to spend the next few slides talking through a few complications that we've seen and how we manage them. Um It's possible obviously, as you've seen earlier in the day to do polls within these talks, I think that's a bit difficult when I'm not actually with you at the time, but I will leave some poll questions there. So you can have a think about what you might do in a similar situation. Our first patient is a 69 year old man who had an extended right hemi collecting me for transverse colon cancer, who was relatively co morbid with diabetes require insulin treatment, hypertension and a previous Michael infection on day one as everybody is on day one, he was doing well, drinking, eating a little bit, but by day three, he still hadn't passed any flatters. Uh, actually by day five, he deteriorated a bit and had been vomiting. His bowels still hadn't opened. His EGFR had dropped a bit from a G fro very 90 preoperatively 2 52 on day five. Well, those abdomen was still soft and appropriately tender for his stage in his recovery. The management means due to this was put him near by mouth to help prevent the vomiting and placing an N G tube and free drainage again to control the vomiting and help prevent the risk of aspiration. We changed all of his medications to intravenous forms and kept him on his side as gail for insulin. Whereas other cases, we may have hoped to get guns down by day five, he had IV fluid replacement in close renal function monitoring to make sure they're G F are improved. The questions that we really wanted to ask ourselves at that point was how we should manage this complication, which at the moment was really just not being able to tolerate anything or really and his bowels not working. We'd yet to make a definite diagnosis of illness. One day five. Should we be thinking about peripheral nutrition? Do we want to think about how we need to feed this gentleman or should we wait till we've got time to wait a bit longer? And should we do a CT scan. At this point. On day seven, we waited a couple more days. On Monday seven, he'd still had nearly liter and a half coming up through his engine in 24 hours. At that point, you placed a picc line, um, to allow peripheral nutrition and performed a CT scan. Uh huh. It's about day 10. Without nutrition, we really need to think about other methods of a feeding patient. So once we get to say six or seven, if we don't think the patient's going to turn a corner pretty soon, then we want to think about other methods of feeding. It can take a couple of days in my hospital to get a picc line in and get a patient into award environment where they can have PM. Um So day six or seven is when we start thinking about that, our CT scan that we did on day seven had the picture you see you see in front of you was very dilated stomach and actually the energy was replaced at that point to allow better drainage. And also alias was this very dilated small bowel? No obvious transition point. The reason we wanted to do a CT scan was to make sure we've excluded any other um problems, any kind of any mechanical obstruction rather than just ideas and to make sure we excluded ports like her and small bowel being stuck through any mesenteric defect and also any other problems that might be driving his idea. So whether he had an intradermal collection that might be driving Eilis, although that's unusual with his inflammatory marker or normal by day, this gentleman had more up as energy. So about 3.5 liters in 24 hours. And actually, we're pretty happy that we've got some plan in place at that point. However, his renal function was maintained with this IV fluids. Um By day nine, his engines started settling. His bowser's started opening, so we probably turned a corner with him. Um, we were able to speak at the energy and aspirated four hourly and increases all fluids. By 12, we could take his energy out and let him eat a little bit. By day 13, we started tapering his P M which stopped one day 15 and once his electrolytes been reviewed and his insulin had also been reviewed were just discharged him well on day 20. So ideas is a really common problem after colorectal surgery. Uh, an emergency laparotomy is also usually settles with time and it can be a bit of a waiting game. This can be particularly frustrating for patient's and worrying for the clinical team. It's important to concentrate fluid balance and make sure that you've got accurate fluid balance, including urine output and check the renal function on a daily basis. You need to think about how patient's are getting their normal medications and how they're getting their nutrition NSCT to exclude like some mechanical obstruction or intraabdominal causes for the eyeless. I'd be particularly concerned that there's something else going on apart from just an eyeless. If patients have got particular pain, aliases, often not particularly painful, just they should have bloated and distended. Um, and if the patient's got abnormal bloods with signs and Eilis, I'd also be concerned there's something more going on. Our next patient is 74 year old gentleman who again had, had extended right? Hemicolectomy for his splenic flexure cancer. He had known liver Mets at the time of his surgery which would be receptible. He had preoperative chemotherapy to manage these and test their biology. His procedure was converted from laproscopic to open as in the previous scenario on day one, he was well, he was on a little bit of Motrin office for his BP and was managing a light diet. But again by day five, he was vomiting uh hemodynamically, he was stable with his metro minal weaned and these inflammatory marker smoke, particularly impressive duties of vomiting and energy was placed. And as in the previous scenario, CT was performed day six um to exclude any mechanical cause of obstruction or any intraabdominal complications that might be causing what we thought would be an alias. As you can see on that CT scan, there was more than just an island and it's free, quite significant amount of free gas and some free fluid um in the upper abdomen. Um concerning for an anastomotic leak. He was well at that point and his inflammation markers weren't particularly impressive. We were concerned his recent chemotherapy might have dampened his immune uh, inflammatory response to an anastomotic leak. So the question at this point is how we're going to manage this patient. Should it be taken back to theater and the joint taken down? Um, even those relatively well given there's a significant amount of free gas on his scan or should he be managed conservatively? After discussion with the patient and his relatives and second opinions from the clinical team. And we felt the gentleman was well enough to manage nonoperatively. He was started on IV antibiotics given just sips of water, um orally as well as a picc line for peripheral nutrition. We did this because his blood's actually were fairly unremarkable and the patient's very well and particularly adverse to another operation. By day eight, he was managing some more fluids and he felt it was safe to build up which was taking orally. His PN was weaned down and his antibiotics. Um we were stopped and he was able to be discharged on day 12. This third patient is a 44 year old gentleman who has had a high anterior section formula presc optically. His medical history included mild learning difficulties and elements of anxiety because of the height of the joint. He was not d functioned. There was also some discussion about whether how well he might manage a stone or should he need one? One day one? He was here in a dynamically well, but in significant pain really from the outset PT was eating, he had a white cell count of 17 immediately postoperatively. Obviously, on day one, his bowels haven't worked by day three. He was take a card ick and Pyrexia. Well, and his CRP had gone up over 200 on day four because of this, uh CT scan was performed which shows the picture that you can see in front of you there. So he's got significant amount of free gas um and fluid and probably fecal material around the anastomosis in keeping with a significant s Tomatis. Great damn early the following morning. Um he went back to theater for an emergency laparotomy and there was significant perfect contamination in the anastomosis was taken down with an end colostomy made. Um He recovered well. Uh He managed his stoma care reasonably. Uh He had several days of IV antibiotics, although his anxiety did make things more challenging for him. He um discharged independently. Um The communication was a bit difficult with him in his mom's significant support on the wards with his post operative care. So, anastomotic leak um is a significant complication in colorectal surgery um can be managed as you see in that his last two cases in different ways. Um The I think it's important to remember that we need to treat the patient rather than just the CT findings alone and we have and although an asthmatic leak is one term, it represents a health spectrum of clinical pictures. It's really important to manage the patient rather than just the CC findings. Um obviously, if patients are completely well, and you made on a CT scan, something different, completely different and you found a few bubbles of gas around the anastomosis, then the decision to manage them nonoperatively is relatively straightforward and equally like the last patient we've spoken about if they're take a Codec pyrexia in significant pain. And I think pain is really important feature. Um uh I'm concerned about patient's who are in pain from the outset. I think those patient's every laparotomy really isn't, isn't without question. However, the great cases which represents all of the patient's in the middle of those two cases. Um I think it's important to give good first aid against. Make sure I've done all the, all the basic things. We'll make sure really tight fluid monitoring on, make sure we've got daily blood to make sure the antibiotics are being given on time and we're keeping an eye on a lactate. Um And I would often ask a consultant colleague for an opinion of a patient in that gray area between the two ends of the an asthmatic league spectrum so that we've had a couple of heads together to think about how my manage his patient. It's really important to keep family and friends and patient involved in these cases, complications can keep patients in hospital a significant amount of time. And that's frustrating and worrying um for patient's who hope there was come out of hospital day five without any problems because patients have to think that to, to be able to go through with some of the operations that we perform. So it's very important to keep patient's and um next of kin um involved as planned develop and whilst managing complications, there is a consensus document from the ACP about management anastomotic leakage a little bit older. Now, it's published in 2016. And if you go on the website and search and systematic league and the papers there, so you can look at the other evidence behind what we shouldn't, shouldn't do with anastomotic leaks. So take home message is for uh short talk on on the post doctor. Complications are really the home you spider senses, make sure you spend plenty of time in the wards. Do the ward rounds have a look at patient and you get a feel for what a normal variety of normal recovery is versus somebody who's not following that pathway. And when you feel uneasy about the patient, make sure you actually make sure you check their blood again. Keep a close eye on them, go back and see them again because they'll be the ones that need your attention. Make sure if you're worried about complications, we read through all of the notes, including the preoperative letters to see what the surgeons were worried about when they're performing this operation. Remember to provide really good first aid on the ward. Make sure the simple things are done thoroughly, make sure the antidotes are given, make sure gas is done, make sure catheter's put in. Um and then investigate patient's appropriately with imaging. Remember to talk to patients and relatives and what can be a particularly worrying time for them. And I think some homework following um this talk would be to watch how your different consultants manage um complications and watch how they manage both their own complications. And um those of their colleagues, it can be much easier to be objective about a patient that isn't yours. And I think that's really a really important thing about working and to making sure you get a second opinion about managing what can be difficult cases. Thank you.