Preface

Complications are part of the life as a surgeon, hence the popular saying, “The only surgeons who don't have surgical complications are those who don't operate.” Many complications are unavoidable. For example, a small percentage of wound infections will always occur in patients with perforated appendicitis, despite meticulous technique and the use of properly timed preoperative antibiotics. Those who leave all contaminated wounds open may never have to report a wound infection, but is it worth submitting all children to the discomfort of an open wound and dressing changes to avoid a 5-10% rate of wound infection? Personally, I don't think so, and I accept the fact that I will have to report a certain number of these complications. However, other than these predictable and, to a certain extent, unavoidable complications, there are some that are severe, potentially preventable, or cause less morbidity if recognized early. This issue of Seminars will focus on this type of adverse event.

As pediatric surgeons, we have all encountered situations where we avoided a serious complication or recognized it early because of our own experience, the experience of a colleague, our learning from the literature, or presentations at meetings/conferences. For example, the relationship between an aorto-esophageal fistula and the presence of an indwelling nasogastric tube in a patient with a vascular ring is not something you necessarily learn during residency training or from reading textbooks in preparation for exams. Yet when you see it once, and you read the literature to find out it is “well-known,” you want to reach out to all of your colleagues all over the world and cry out loud so it never happens again. This is what we did, but what remains of a published case report 15 years later?1

Having encountered other cases of preventable life-threatening and indeed lethal complications over the years, I felt the urge to share these experiences with my colleagues. The idea of having a Seminars issue on this topic was shared with Dr. Grosfeld, who approved such an endeavor. Even though my own complications might have filled the entire issue (!), I had to enlist the help of other contributors. To that effect, I proposed to have a special “Complications” session during the 2008 annual meeting of the Canadian Association of Pediatric Surgeons (CAPS) in Toronto. This was endorsed by the Program Committee Chair, Dr. Natalie Yanchar, as well as the CAPS president, Dr. Geoff Blair. The call for abstract therefore included a special mention of this session, and the session was co-chaired by Dr. Jacques Guilbert, who represented the Canadian Medical Protective Association, a medical defense organization that provides assistance to its members (95% of Canadian physicians) when they face medico-legal difficulties related to their practice. Most of the articles originate from this session, with a few more coming from an e-mail request to all North American Pediatric Surgery Program Directors. Unlike usual issues of Seminars, where review articles are used to update a particular topic, this one contains several case reports that illustrate a variety of underreported severe complications. It is impossible to cover all life-threatening complications encountered in practice, but the following articles provide a sample.

Many pediatric surgeons have adopted the minimally invasive Nuss technique to repair pectus excavatum deformities. Once in a while, we hear about a serious complication, often “through the grapevine,” and we think this will never happen to our patients. In the first article, four experienced surgeons share their experiences with a life-threatening complication encountered during the Nuss procedure, despite meticulous technique. My coronaries went into spasm just reading the case reports. Who would ever have thought that a patient could die at the time of bar removal? While going over the article, I remembered two near-misses that I had myself. In one case in my early experience, my fellow placed the trocar a bit low and did not angulate it cephalad enough, despite my warning. When we put the scope in, we could clearly see liver parenchyma. There was no bleeding and no sequelae, but thank God, the trocar did not enter a hepatic vein while insufflating CO2! In a more recent patient with a “Grand Canyon” deformity, I had difficulty having good visualization when passing the dissector for the second bar, in part because the CO2 was leaking along the tract of the first bar. When I finally increased the insufflation rate and had an assistant keep pressure over the exit sites of the first bar, I saw that the tip of the dissector had gone posterior to the superior vena cava (SVC). Again, I had the good fortune of not lacerating the SVC. Imagine if the bar had been placed along the tract, compressing the SVC under the chest wall! There is no doubt: you have to see what you are doing and take the time necessary. Bouchard and colleagues tell us that, even then, complications may occur, and they clearly explain which patients present greater risks.

We all insert central lines and are aware of complications. Yet it took many years and many embolized catheters before the companies making them inserted a warning in the package about too medial placement in children, leading to a “pinch” between clavicle and first rib with shoulder movements. This causes shearing and eventual transection of the catheter with distal embolization of the tip. But then, who reads the instructions packaged with all the devices we use? Certainly, we all should periodically review these, because the manufacturers' recommendations may change over time; yet, many of the complications are not listed in these inserts. Askegard-Giesmann and her colleagues review the rare but serious complications of central line insertion and provide advice for early recognition. Among their recommendations is the use of fluoroscopy for all central line insertions. This may help to prevent inadequate catheter tip placement, which could result in delayed migration of the catheter, leading to such catastrophic consequences as paraplegia.2 Rare and unpredictable complications may always occur, for example, a right hydrothorax from an umbilical venous line as we have seen; the key is to be alert and aware of all the possible complications. In the following article, Bass and Halton reviewed their experience with skin erosion over ports and offer tips for prevention. Failure to promptly recognize and appropriately treat this problem can lead to life-threatening sepsis.

The placement of gastrostomies is another common operation in our specialty, whether done percutaneously under endoscopic guidance (PEG), by laparoscopy, “open,” or using a combination of techniques. It is often considered a minor procedure, a necessary “pain.” Tube changes are considered an even lesser act, often left to the most junior member of the surgical team. Yet severe complications occur, sometimes even in experienced hands. Beres and colleagues combine the experience in two centers to present several of these complications, some of which were lethal. As one colorful program director put it: “we hate to see those luncho-abdomens”! The authors of this article offer ways in which to prevent such complications from happening or from causing additional morbidity. In the following article, Vervloessem and his co-authors, reviewing their experience over 16 years, identify the presence of a preexisting ventriculoperitoneal shunt as a significant risk factor for major complications after PEG and propose laparoscopic guidance during the PEG in these patients.

Gastric volvulus is an ill-defined pathology. Indeed, it may present as a chronic and recurrent phenomenon without any underlying cause, whereas in other cases it can present acutely and may be associated with diaphragmatic defects. In the latter instance, failure of early recognition may have disastrous consequences, as illustrated in the article by Gerstle and colleagues. Their report also raises important questions about the use of new techniques and the amount of information given to patients and families before discharge from hospital. For example, do we inform families about the risks and symptoms of recurrent herniation after repair of congenital diaphragmatic hernia, especially if a prosthetic patch was required, or if a thoracoscopic repair was performed? We may mention it as one of many possible complications, but most often there are no specific written instructions provided. Several years ago, we had a baby return to our hospital in shock from a small bowel obstruction (SBO) 2 months after a pyloromyotomy; he had been admitted to a community hospital for 24 hours for “gastroenteritis.” Since then, our written discharge instructions specify the possibility of SBO after any abdominal operation, whether open or minimally invasive, and explain its signs and symptoms.

The next article, by Abdalwahab and colleagues, describes fistulization from gastric tubes/gastric pull-up for esophageal replacement. Although this complication is rare and may be difficult to prevent, its early recognition would limit morbidity and even mortality as illustrated in their cases.

Next, Ryckman warns us of an unreported complication of spring-loaded silos placed for gradual reduction of gastroschisis. Although these silos are often placed electively to allow for a gentler reduction of the bowel, in one of the cases, the pressure applied at the apex of the silo did not reduce the bowel, but instead increased the pressure at the base of the sac, leading to venous infarction of the exteriorized small intestine.

In another article by Ryckman, we read about a devastating complication: paraplegia occurring after resection of a chest wall tumor. Bleeding at the time of surgery was presumed to be from intercostals vessels, but instead was coming from hugely enlarged veins of Batson's plexus. Intraoperative packing controlled the bleeding from within the chest, but the hematoma and surgicel together produced cord compression. Some might say, “you should have known,” but no one has ever reported enlargement of epidural veins associated with a PNET. Anyone who reads this report will also never forget.

Some of the textbook teaching in one specialty seems to go against the thinking in another specialty. I was always surprised to hear some anesthesiologists tell me that they were trying to place the endotracheal tube beyond the fistula in newborns with esophageal atresia and distal tracheoesophageal fistula. Several times I showed them with preoperative rigid bronchoscopy that it was not practical, especially when done blindly, because encountering a very low or trifurcation fistula is not rare. But it is not their fault, because they are following what their textbooks say! Alabbad reports a patient on whom this was done, with the endotracheal tube slipping in a fistula that was larger than the distal trachea, ultimately resulting in patient demise. This complication could be eliminated with the liberal use of bronchoscopy, both rigid and flexible, preoperatively and intraoperatively when needed.

To finish with lethal complications from our center, we report on a midgut volvulus caused by a large abdominal cyst in a neonate, initially thought to be of ovarian origin and aspirated under ultrasound guidance. This case was previously reported at meetings and briefly mentioned as part of a publication on intestinal duplication,3 but its severity warrants a dedicated publication. It serves as an example that asymptomatic intestinal duplication cysts cannot be ignored, and that large cysts of presumed ovarian origin warrant surgical exploration. Although one hates to do unnecessary surgery, the risks are sometimes less than the risks of observation.

The final report focuses not on the prevention of a specific complication, but on how to react when an unexpected serious complication occurs. Dr. Skarsgard provides a detailed analysis on how to manage adverse events occurring during elective ambulatory surgery. We all hope that we are never faced with such a situation, but we have to be prepared just in case. Dr. Skarsgard's thoughtful description could not have provided a better conclusion to this issue of Seminars, in this era where professionalism and disclosure are words that sometimes appear to be more important than knowledge and technique within our governing bodies.

Although having a bad complication is difficult, publishing it is even more difficult. There is a fear of lawsuits, and indeed lawyers will advise you against publishing a case where there is ongoing litigation. It takes guts to tell others about your complications, and I am indebted to the contributors, who agreed to share their experience for the benefit of future patients. There are textbooks dedicated to complications; this edition of Seminars is not meant to replace them, but to raise your awareness and encourage you to read these books and report your complications for the benefit of your colleagues and their patients. One problem is that few people read books from cover to cover; often we refer to them only when a specific problem arises. Perhaps we should have a sort of “complication-alert” e-mail weekly or monthly, where pediatric surgeons could share their complications. Problems encountered could be stated very briefly, much like the Letter to the Editor published many years ago to warn about the use of the ultrasonic dissector along the ureter when resecting an extensive retroperitoneal neuroblastoma.4