GET THE APP

Post-Operative Wound Complications Following Abdominal Surgery in Children: A Single Centre Experience

Research - Archives of Clinical and Experimental Surgery (2021)

Post-Operative Wound Complications Following Abdominal Surgery in Children: A Single Centre Experience

Chukwubuike Kevin Emeka*
 
Pediatric Surgery Unit, Department of Surgery, Enugu State University Teaching Hospital, Enugu, Nigeria
 
*Corresponding Author:
Chukwubuike Kevin Emeka, Pediatric Surgery Unit, Department of Surgery, Enugu State University Teaching Hospital, Enugu, Nigeria, Email: [email protected]

Received Date: Sep 08, 2021 / Accepted Date: Sep 22, 2021 / Published Date: Sep 29, 2021

Abstract

Background: Post-operative wound complication may be defined as any negative wound outcome as perceived either by the surgeon or by the patient. The aim of this study was to evaluate a single center’s experience with regards to the pattern and management outcome of post-operative wound complications in children who underwent abdominal surgery.

Materials and methods: This was a retrospective study conducted on children who had laparotomy (emergency and elective) at the pediatric surgery unit of Enugu State University Teaching Hospital (ESUTH), Enugu, Nigeria between January 2010 and December 2019.

Results: A total of 1,914 laparotomies were performed during the study period but only 402 cases had post-operative wound complications, accounting for 21% of all the laparotomies. There was male predominance and children younger than 6 years of age were mostly affected. Majority of the patients presented more than 72 hours after onset of their symptoms that necessitated the initial surgery and the mean duration of hospital stay was 21 days. Typhoid intestinal perforation was the most common pathology and most of the cases were emergencies. Surgical site infection was the most common postoperative wound complication and mortality occurred in 2 (0.5%) patients.

Conclusion: Post-operative wound complications are not uncommon and may be associated with some morbidity and mortality. Future studies should identify modifiable factors that may reduce the occurrence of these post-operative complications.

Keywords

Colorectal liver metastases; Surgery; Liver-first approach; Classical approach; Colon-first approach

Introduction

Post-operative wound complications may be defined as complications arising from the surgical wound occurring within 30 days of a surgical procedure. It is significant source of post-operative morbidity and a burden on both the patients and the surgeons [1]. Post-operative wound complications range from mild cases requiring local wound care and antibiotics to severe cases needing reoperation; wound infections and wound dehiscence are well known post-operative complications [2]. Wound complications are associated with prolonged hospitalization and associated increased expense [3]. Several studies have reported wide variations in the incidence of post-operative wound complications ranging from 2.5% to 20% [4,5]. Factors affecting post-operative wound complications may be local or systemic. The local factors include the degree of wound contamination and surgical technique [6]. Neonatal age and coexisting morbidity are some of the systemic factors that may play important roles in the etiopathogenesis of wound complications [7]. Surgical incision during surgical procedure is associated with disruption of local vascular supply, thrombosis of the vessels and tissue hypoxia. Disruption of the tissue integrity goes with proliferation of bacteria in the wound and tissues; this affects the healing process and increases the risk of wound infection and wound dehiscence [8]. Presence of bacteria affects all the processes of healing and promotes impairment of collagen synthesis which promotes wound dehiscence by decreasing suture-holding capacity of the tissue [9-27]. Generally, post-operative wound complications can be patient related, disease related, surgeon related and treatment related [20]. The aim of this study was to evaluate a single center’s experience with regards to the pattern and management outcome of post-operative wound complications in children who underwent abdominal surgery.

Results

Patients’ demographics

A total of 1,914 laparotomies were performed during the study period but only 402 cases had post-operative wound complications, accounting for 21% of all the laparotomies, and form the basis of this report. There were 303 males (75.4%) and 99 females (24.6%), which corresponds to a male to female ratio of 3:1. Details are depicted in Table 1.

Table 1: Demographic characteristics of the patients (N=402).

Gender  
Male  303 (75.4%)
Female 99 (24.6%)
Age group of the patients  
Neonate (less than one month)  35 (8.7%)
One month-6 years 187 (46.5%)
Greater than 6 years 180 (44.8%)
Median age of the patients 6 years (1 week - 15 years)
Median duration of symptoms prior to presentation 3 days (1–14)
Presented within 24 hours 41 (10.2%)
Presented between 24 and 72 hours 92 (22.9%)
Presented after 72 hours 269 (66.9%)
Median duration from presentation to surgery 5 days (1 - 10)
The mean duration of hospital stay 5 days (1 - 10)

Clinical diagnosis: The clinical diagnoses of the patients are shown in Table 2.

Table 2: Clinical diagnosis of the patients (N=402).

Clinical diagnosis Number of patients (%)
Typhoid intestinal perforation  (TIP) 135 (33.6)
Intussusception 131 (32.6)
Complicated external hernia (CEH)   46 (11.4)
Intestinal atresia 33 (8.2)
Perforated appendix 32 (8.0)
Adhesive intestinal obstruction (AIO) 14 (3.5)
Abdominal trauma 11 (2.7)

Urgency of the operation: Three hundred and sixty- nine (91.8%) cases were performed as emergencies while 33 (8.2%) cases were performed as elective cases.

Intra-operative finding and definitive operative procedure performed: The operative findings and the treatment rendered is shown in Table 3.

Table 3: Operative findings and treatment.

Pathology Operative finding Treatment Number of patients (%)
TIP       Single ileal perforation Primary closure 90 (66.7) 
   Multiple perforations Ileostomy 45 (33.3)     
Intussusception Viable bowel Manual reduction 33 (25.2)
  Non-viable bowel  RHC + ITA  98 (74.8)
Complicated hernia   Viable bowel Repair 13 (28.3)
  Non-viable bowel Resection and anastomosis 33 (71.7)
Intestinal atresia  Viable bowel Resection and anastomosis 33 (100)
Ruptured appendix  Pyoperitoneum  Abscess drainage 32 (100)
AIO  Viable bowel Adhesiolysis 10 (71.4)
   Non-viable bowel Resection and anastomosis 4 (28.6)
Abdominal trauma   Shattered spleen Splenectomy 11 (100)

Wound complications: The complications that happened to the wounds are reflected in Table 4.

Table 4: Post-operative wound complications (N=402).

Complications Number of patients (%)
Surgical site infection  
Superficial 218 (54.3)
Deep 66 (16.4)
Wound disruption (wound dehiscence)  42 (10.4)
Wound and fascial rupture (burst abdomen)  28 (7.0)
Incisional hernia 19 (4.7)
Hypertrophied scar 15 (3.7)
Keloid 14 (3.5)

Outcome of treatment: Three hundred and seventy- one (92.3%) patients achieved full recovery and were discharged home. Twenty-nine (7.2%) patients who had keloid and hypertrophied scars were referred to the plastic surgery unit. Two (0.5%) patients expired due to overwhelming sepsis.

Discussion

Some authors have defined post-operative complications as any negative post-operative outcome as perceived either by the surgeon or by the patient [10]. The history of wounds and its healing is, in a sense, the history of humankind. One of the oldest manuscripts known to man is a clay tablet that dates back to 2200 BC. This tablet describes the “three healing gestures”- washing the wounds, making the plasters and bandaging the wound [11]. There are factors that may predispose the patient to problems of healing. Technical (intra-operative) problems may increase the likelihood of wound infection and dehiscence [12]. There are also post-operative management protocols that can prevent or increase wound healing problems.

In the present study, the incidence of wound complication is comparable to the report of a study from Kaduna, Nigeria [13]. However, a study from Manipal, India reported a wound complication incidence of 13%. The differences in the incidence of post-operative wound complications may be due to the nature of the surgery such as clean or dirty surgeries. Immune status of the patient is also an important consideration:

Immunosuppressed patients are prone to wound complications [14]. There was male predominance in the current study. This is consistent with the findings of other researchers [2, 15]. In the index study, children who were less than 6 years of age were mostly affected. Vary et al., also reported higher incidence of post-operative wound complications in older children [16]. The septic nature of the abdominal pathologies with associated peritonitis may explain the high incidence of wound complications in older children. The late presentation of our patients is reflected in the 3-day lag period between the onset of symptoms and presentation to the hospital. Low level of parental enlightenment and poverty may explain this delayed presentation. One study from Mozambique reported distance from the hospital as a predictor of mortality in children who presented with pediatric emergencies [17]. The median interval between presentation and surgery of 5 days was the time required to investigate and optimize the patient. It took this long to get the patients to theatre because some of the cases were elective cases. Again, deranged hematological and biochemical parameters entailed prolonged period of optimization prior to surgery. The mean duration of hospital stay of 21 days could be explained by the prolonged hospitalization and morbidity associated with treating the post-operative wound complications. Tumescent et al reported the morbidity associated with post-operative wound complications [18]. The increased hospital stay is also tied to higher treatment cost.

In the current study, typhoid intestinal perforation was the most common pathology that resulted in post-operative wound complications. Other authors also reported high occurrence of wound complications following surgery for typhoid intestinal perforation [19, 20]. Typhoid fever, also known as enteric fever, is a common multisystem infection caused by the bacteria Salmonella enterica serovar typhi and Salmonella enterica serovar paratyphi A and B which are transmitted through feco-oral route [21]. Typhoid perforations occur due to ulceration of the Peyer’s patches mostly at the terminal ileum. Exposure of the surgical wound to unsterile intestinal contents and infectious agents including pus during surgery may explain the high wound infections in typhoid intestinal perforation. Operation for intussusception accounted for the second most common cause of post-operative wound complication. One study from Lagos, Nigeria reported wound complications, following surgery for intussusception, in about one-third of the patients [22]. In a developing country like Nigeria, late presentation of children with intussusception and associated intestinal gangrene with perforation may explain the high wound complication rate. Surgeries that entail entering the bowel lumen and contact with pus such as in perforated appendix and strangulated hernias are also associated with wound complications.

More than 90 percent of the cases in the present study were performed as emergency surgeries. Other studies also reported more post-operative wound complications in emergency surgeries when compared with elective surgeries [2,10]. The reason for the higher complications following emergency surgery may be due to risks (life threatening) associated with emergencies, inadequate preparations and little or no time for the patient optimization before surgery. Second ly, the best of hands may not be available to handle emergency surgeries which mostly happen at night.

The operative procedure performed depended on the findings at surgery. For instance, where there is gangrenous bowel, resection of the non-viable bowel was done and the bowel continuity restored by anastomosis. When there is intestinal perforation like in typhoid intestinal perforation, the edges of the perforation was freshened and the perforation repaired. However, segmental bowel resection and anastomosis can also be performed in typhoid intestinal perforation [23].

Surgical site infection was the most common post-operative wound complication in the current study. Surgical site infection which was previously known as post-operative wound infection is defined as that infection presenting up to 30 days after a surgical procedure if no prosthetic is placed and up to 1 year if a prosthetic is implanted in the patient [24]. In the index study, the diagnosis of surgical site infection was made based on seropurulent wound effluent and growth of an organism on culture. Escherichia coli were the most commonly grown organism. Other series on wound complications also reported surgical site infection as the most common post-operative wound complication [2,10]. Wound dehiscence and burst abdomen may have resulted from the surgeon’s factor such as surgeon’s technique or from the patient’s factor such as co-morbidities. One study from Netherlands reported that the major risk factors for abdominal wound dehiscence are age younger than 1 year, wound infection, median incision and emergency surgery [25]. Incisional hernia may not be obvious during the initial hospital admission but manifest a few months after surgery. Incisional hernia may result from poor surgical technique or use of inappropriate suture during fascia closure. Keloid and hypertrophic scars are pathological scars that result from aberrant wound healing [26]. Treatment of these pathological scars is handled by the plastic surgeons.

Treatment of the specific post-operative wound complication depended on the specific type. For instance, wound infection was handled by serial wound dressing and antibiotics based on the laboratory results. Wound dehiscence and burst abdomen require delayed wound closure and surgical closure using tension sutures respectively. The overall outcome of treatment post-operative wound complication was good. However, mortality may occur from recalcitrant infections. Ameh et al., also reported mortalities in children who developed post-operative complications [27].

Conclusion

Post-operative wound complications are not uncommon and may be associated with some morbidity and mortality. Surgeon-related and patient-related factors may be involved and require modification to decrease the incidence of these complications. Future prospective studies are required to determine the factors that influence post-operative wound complications.

Limitations of the Study

1. This study is a single center experience and may not be generalizable to other centers.

2. The specific factors that affect the occurrence of these wound complications were not assessed.

References