Textbook of Iatrogenic Pathology

Simona Gurzu, Ioan Jung

• Publisher: Bentham Science Publishers
• Year: 2017
• ISBN:
  9781681085142
• Topic: Medicine
• Subtopic: Pathology

This book is a concise textbook of iatrogenic pathology. Chapters cover iatrogenesis relevant to a broad range of medical subspecialties (cardiology, gastroenterology, gynecology, neurology, endocrinology and much more). The book presents an introduction to iatrogenesis which is followed by chapter-wise descriptions of iatrogenic lesions (lesions due to adverse drug reactions, lesions occurring during diagnosis and consequences of various therapeutic interventions) of the organs and systems of the body.
This textbook is a handy resource on iatrogenic pathology for medical students and working professionals (clinical and nursing staff) involved in a range of medical subspecialties.

Iatrogenic Pathology in Surgery

Tivadar Jr. Bara^*, Bogdan Andrei Suciu, Tivadar Bara

Department of Surgery, University of Medicine and Pharmacy, Tirgu-Mures, Romania

Abstract

Surgical intervention remains a trauma for patients even given modern techniques and the use of highly specialized instruments. Any surgical maneuver can cause injuries and complications. The severity of such injuries is determined by the disease itself, the patient's comorbidities and the surgeon's experience. In this chapter, we present the iatrogenic complications arising following major surgeries performed openly or laparoscopically. In the first section, general complications, such as hemorrhage, fever, ileus and abscesses, are presented. Next, organ-related complications occurring during laparotomy, drainage of the abdominal cavity or abdominal wall reconstruction are described in detail. We then turn to the specific intra- and postoperative complications of various organs’ surgical treatment due to erroneous surgery indications, vascular lesions and lesions of the neighboring organs. We describe complications in the surgery of the mediastinum, thoracic and abdominal cavity and describe the particularities of thyroid, lung, esophagus, stomach, small intestine, appendix, colon, pancreas, hepatobiliary tract and hernia surgery and postoperative parietal defects. Complications occurring as a result of laparoscopic intervention, erroneous indications or complications in performing pneumoperitoneum during insertion of the trocars are also presented. Finally, we consider the specific iatrogenic complications arising during minimally invasive bile, hiatal hernia, cardiac achalasia, spleen and morbid obesity (gastric sleeve and gastroplication) surgery.

Keywords: Abscess, Chylothorax, Duodenal stump insufficiency, Fistula, Hematoma of the scrotum, Hemoperitoneum, Hemopneumothorax, Mediastinitis, Pancreas, Peritonitis, Suture dehiscence.

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^* Corresponding author Tivadar Jr. Bara: Department of Surgery, University of Medicine and Pharmacy, Tirgu-Mures, Romania; Tel/Fax: [phone]; E-mail: [email protected]

INTRODUCTION

The severity of surgery-related injuries is directly influenced by the type of disease, the patient’s comorbidities and the surgeon’s experience. Unexpected complications may manifest after surgery, which can spoil the patient’s prognosis and endanger his life. The surgeon thus faces a new pathology, which is often difficult to diagnose or treat because it is caused by the original disease or the surgical procedure used during treatment.

GENERAL COMPLICATIONS

The purpose of the atraumatic, tissue-friendly surgical technique is to minimize tissue damage, preserve vascular and nervous integrity, and prevent additional injury. Thus, we can ensure optimal tissue regeneration and reduce the rate of intra- or postoperative complications.

Fever of unknown origin, pain, infections, anastomotic insufficiency and wound dehiscence appearing after surgery is often caused by nonuse of atraumatic techniques. The requirements for the application of atraumatic surgical techniques are: expertise in the field of surgical anatomy, biomechanics and physiology of wound healing, and an excellent knowledge of the application of special surgical tools used during surgery. These techniques prevail, especially, during tissue dissection, when blood-free anatomic target areas are created by dividing the tissues. In order to prevent complications, correct hemostasis and knowledge of the advantages and disadvantages of the preparation techniques, as well as their proper application, are required (sharp, dull, electrical, ultrasonic, etc.).

To remove the blood, whey and tissue fragments created in the surgical area, it may be necessary to use drainage. This, however, is not a substitution for atraumatic technique. The rate of drainage-related complications depends on the quality, size, location and timing of surgical tube use.

The quality of suture is also an aspect of the atraumatic technique, most trauma being caused by the inadequate use of surgical needles. Nowadays, the use of atraumatic needles is more common, yet the diameter of the needle, its profile (round, triangular) and thickness, as well as the quality of the thread (monofilament, multifilament, absorbable, etc.) are all important considerations. The suture method also affects the quality of the atraumatic technique. Knots in suturing with dense stitches cause tissue ischemia and necrosis.

Aggressive surgical maneuvers induce tissue trauma with further functional or morphological damage [1].

SURGERY OF THE MEDIASTINAL CAVITY

In this section, we will present the lesions related to surgery of the esophagus and thyroid gland.

Iatrogenic Lesions in Surgery of the Esophagus

Surgery of the Esophageal Diverticula

Diverticulectomy is indicated in symptomatic cases (dysphagia, regurgitation) and not for incidentally identified pulsating diverticula. Surgery is also indicated in associated inflammation, hemorrhages and chronically aspirated food remnants with aspirated pneumonia or lung fistulae. Reflux disease can be resolved with anti-reflux surgery.

Complications of such surgery can be related to the surgical technique and relate to recurrence as a result of clogging the diverticulum or incomplete myotomy. Sutures applied to close the diverticulum’s aperture may cause stenosis, which can induce increased pressure and, in turn, lead to suture dehiscence.

Intraoperative Injuries include the following main lesions: hemorrhages (injuries of the common carotid artery, inferior thyroid artery or jugular vein), injuries of the recurrent laryngeal nerve (with postoperative hoarseness) and perforation of surrounding organs (esophagus, stomach, spleen, liver, pleura, lung).

Postoperative Injuries include fistulae (especially for Zenker’s diverticulum), dehiscence of the epiphrenic diverticulum (with life-threatening mediastinitis displayed with dyspnea, fever, retrosternal pain, pleural and mediastinal fluid accumulation), stenosis (with dysphagia) and diverticulum recurrence (errors in surgical technique) [1^-4].

Surgery of Malignant Tumors of the Esophagus

Incorrect Surgical Indication for esophagectomy can be the result of weak investigation of the patient. Improper preoperative assessment of metastatic status is a relatively common error, esophagectomy not being recommended in advanced stages, when the tumor infiltrates the respiratory tract, recurrent laryngeal nerve, lung or thyroid, even in the presence of liver or distant metastases. For example, in one of our cases, we intended to remove a diaphragmatic tumor reported preoperatively in a CT scan. Intraoperatively, a huge tumor of the middle third esophagus with infiltration of the trachea carina was identified, changing the operative protocol. The patient died 12 days after the surgery. This case attests to the necessity of attentive evaluation of the patient and choice of surgical procedure based on the tumor stage and localization, the patient’s status and comorbidities, as well as the surgeon’s experience and skill.

There is no consensus on the radical surgical treatment for malignant tumors of the esophagus. For subtotal esophagectomy, three principles should be respected: transhiatal method (Orringer), transthoracic block dissection (Skinner), and “two fielded” lymph node dissection (Akiyama) [1, 5].

Errors Regarding the Surgical Technique are mainly related to the surgeon’s experience. For potentially curative tumors, oncologic radicalism and preserving esophageal function should be the main objectives, taking into account the patient’s status and comorbidities. To preserve functionality, a Roux loop constructed from the jejunum is ideal, however such a loop long enough to replace the whole esophagus is not possible. Replacement of the esophagus with stomach “tube” is effective. However, during the replacement, in some cases, we discover that its length is still not enough. Functionality is then better preserved using a retrosternally built gastric tube. The risk of duodenal gastroesophageal reflux is decreased, but the risk of dehiscence increases. The use of a colon tube is associated with a higher rate of postoperative complications [1, 6].

Intraoperative injuries during esophagectomy without thoracotomy comprise a large spectrum of lesions, including the following main complications: injury or perforation of the abdominal esophagus (with mediastinitis, gastritis or purulent complications), injury of the left hepatic lobe (during preparation of the abdominal esophagus), injury of the spleen (during preparation of the “gastric tube”), injury of the pancreas (during removal of adherences between the stomach and pancreas), injury of the stomach (during preparation of the “gastric tube”), vascular lesions (with hematoma formation or gastric wall ischemia), injuries of the recurrent laryngeal nerve, injury of the trachea or pleura (risk of pneumo- or hemothorax) and cardiac arrhythmia (during transhiatal preparation of the esophagus) [6^-8].

Intraoperative Injuries during Esophagectomy with Thoracotomy include the following complications: pleural or pulmonary injuries (during removal of the pleural adherences), hemorrhages (lesions of the intercostal vessels, such as vena azygos, or of the aortic branches) and injuries of the thoracic duct (risk of chylothorax), trachea and bronchi [6^-8].

Postoperative Complications are relatively common and primarily involve cervical,...

Table of contents

• Welcome
• Table of Content
• Title Page
• BENTHAM SCIENCE PUBLISHERS LTD.
• FOREWORD
• PREFACE
• List of Contributors
• ABBREVIATIONS
• Adverse Drug Reactions
• Radiation-Induced Lesions
• Iatrogenic Immunopathology
• Iatrogenic Pathology of the Cardiovascular System
• Iatrogenic Pathology of the Lungs and Airways
• Iatrogenic Pathology of Gastrointestinal Tract
• Iatrogenic Pathology of the Peritoneum and Retroperitoneum
• Iatrogenic Pathology of the Liver, Gallbladder and Pancreas
• Iatrogenic Pathology of the Kidney and Urinary System
• Iatrogenic Pathology of the Female Genital System and Breast
• Iatrogenic Pathology of the Male Genital System
• Iatrogenic Pathology of Bone Marrow and Lymphoid Tissue
• Iatrogenic Pathology of the Skin and Subcutaneous Tissue
• Iatrogenic Lesions in Neurology
• The Endocrinology and Iatrogenesis
• Iatrogenic Pathology in Anesthesiology and Intensive Care
• Iatrogenic Pathology in Surgery
• Iatrogenic Lesions in Obstetrics and Gynecology
• Iatrogenic Lesions in Neurosurgery