Resolution Of Postoperative Ileus Research Articles

First isolation of Burkholderia tropica from a neonatal patient successfully treated with imipenem

We report the first case of a human Burkholderia tropica infection. The patient was a premature neonate who had necrotizing enterocolitis with bowel perforation requiring surgical intervention. The stoma care and difficulties in feeding were a chronic problem. At the age of almost 4 months he developed septicemia due to B. tropica. Three consecutive blood cultures grew this organism. The organism was cleared from the blood after a course of imipenem and resolution of post-operative ileus. Our case suggests that environmental and plant pathogens can cause human infection especially in those in an immunocompromised condition.

Neonatal Outcome of Gastroschisis Is Mainly Influenced by Nutritional Management

The aim of the study was to evaluate early minimal enteral feeding (MEF) and gradual enteral nutrition increment on neonatal outcome of gastroschisis. An intervention group was prospectively assessed and compared with an observational historical control group. The prospective study relied on a new protocol of enteral nutrition. According to the new protocol, MEF was initiated 5 days after bowel reintegration and milk amounts were increased 12 mL/kg/day. In the control group, enteral nutrition was delayed until resolution of postoperative ileus, and increment of feeding was not systematized. Twenty-two patients were included in the MEF group and compared with 51 control patients. Infants in the control group had lower gestational age (36 vs 35 gestational weeks [GW], P=0.03) and birth weight (2465 vs 2200 g, P=0.05). Time to first enteral nutrition (5 vs 11.5 days, P=0.0005) was significantly shorter in the MEF group. All patients in this group were fully enteral fed at day 60, though 30.4% of patients in the control group still needed parenteral nutrition at day 60 (P=0.004). Incidence of nosocomial infection was reduced (9% of patients vs 40%, P=0.016) and hospital stay tended to be shorter in the MEF group (40 vs 54.5 days, P=0.08). In the univariate analysis, factors influencing the length of parenteral nutrition during the 2 periods were the severity of perivisceritis and new nutritional protocol. In the multivariate analysis, only nutritional protocol was significantly associated with the length of parenteral nutrition (P=0.038). Early MEF and controlled increase of nutritional elements after bowel reintegration significantly improved outcome of gastroschisis in newborns.

Regional anesthesia and patient outcomes: evidence-based medicine

Despite some reticence on the part of both surgical and anesthesiology colleagues, the use of regional anesthesia and analgesia does provide improvement in patient outcomes. Although the majority of available data has examined the effect of epidural anesthesia and analgesia on patient outcomes, an increasing number of studies recently have investigated the effect of peripheral regional techniques (both single-shot and continuous) on outcomes. Overall, the data suggest that the perioperative use of regional anesthesia and analgesia may improve both major (e.g., mortality, major morbidity) and minor (patient-reported) outcomes. The majority of evidence favors an ability of epidural analgesia to reduce postoperative cardiovascular and pulmonary complications, and there is also consistent evidence that epidural analgesia with local anesthetics is associated with faster resolution of postoperative ileus after major abdominal surgery. Regional analgesic techniques, especially when using local anesthetics, provide statistically superior analgesia compared with systemic opioids, although there is insufficient evidence to support improvements in patient-oriented outcomes, such as quality of life and quality of recovery. Nevertheless, there is some controversy regarding the strength of the available data due in part to the presence of methodologic issues present in many studies to date. In addition, any benefits conferred by perioperative regional anesthetic techniques need to be weighed against any potential risks. We will focus our discussion on the benefits of perioperative regional (neuraxial and peripheral) anesthesia and analgesia on patient outcomes.

Review: early feeding after major gynaecological surgery is safe except for an increase in nausea

K Charoenkwan Dr K Charoenkwan, Chiang Mai University, Chiang Mai, Thailand; kicharoe@mail.med.cmu.ac.th In women having major abdominal gynaecological surgery, does early initiation of oral intake of food and fluids increase...

Incidence of minimally invasive colorectal cancer (CRC) surgery in patients treated at NCCN institutions

6575 Background: In May 2004 the Clinical Outcomes of Surgical Therapy Study Group published the results of the North American randomized trial demonstrating that oncologic outcome is similar for laparoscopic assisted and open surgery for CRC. This and other studies have shown quicker recovery with laparoscopic CRC surgery including earlier resolution of postoperative ileus, less discomfort, and earlier discharge from the hospital. The extent to which surgeons have adopted the minimally invasive surgical (MIS) approach in CRC is unknown. Methods: Using the NCCN Colon/Rectal Cancer Outcomes Project Database, 715 patients were identified who underwent CRC resection in 2005–6. The distribution of lesions included right colon (39%), left colon (31%), and rectum (30%). The incidence of MIS for CRC and clinicopathologic features associated with this approach were analyzed by logistic regression; results are reported as odd ratio (OR) with 95% confidence intervals (CI), and significance defined at p<0.05 level. Results: A total of 167 (23%) patients underwent MIS colorectal surgery (laparoscopy in 98% and robotic in 2%). Conversion to open surgery was noted in 33 cases (20%). Surgery was performed in outside institutions in 21% of cases prior to patients presenting to NCCN institutions for further treatment. The MIS approach was more common in colon than rectal cancer (30% vs.12%, OR 2.96, CI 1.94–4.51, p<0.0001). Within the colon cancer cohort, right sided lesions were more likely to be approached with MIS techniques rather than left sided lesions (32% vs. 25%; OR 1.42, CI 1.96–2.21, p<0.0001). Stage I tumors were also more likely to be managed with the less invasive approach: Stage I-41%; II-20%; III-21%; IV-19% (Stage I vs. IV, OR=3.00, CI 1.74–5.16 p<0.0001). No differences in surgical approach were noted based on age, gender, race, Charlson comorbidity score, insurance type, or location of surgery (NCCN vs outside facility). Conclusion: The majority of CRC surgery for patients presenting to NCCN institutions is performed by open techniques. Right sided and early stage CRCs were more likely treated with MIS, possibly related to the less demanding nature of the procedure. The adoption of MIS is expected to rise as surgeons become trained in MIS techniques for CRC. No significant financial relationships to disclose.

Early enteral feeding in newborn surgical patients

Objective We report the results of a multicenter prospective trial of early enteral trophic feeding in a group of 56 neonates who required abdominal surgery for a variety of congenital anomalies. Methods In this clinical study, 33 neonates were fed in the early postoperative period (early enteral nutrition [EEN] group), and the remaining 23 (control [C] group) were fasted until resolution of postoperative ileus. Patients in the EEN group (Kocaeli feeding protocol) received 3 to 5 mL of breast milk every hour through a nasogastric feeding tube, starting a mean of 12 h (8 to 20 h) after surgery. The nasogastric tube was clamped for 40 min after each infusion and then opened for drainage. Groups were further divided into two subgroups according to whether an intestinal anastomosis or laparotomy was performed. The change in daily gastric drainage, time to first stool, day of toleration to full oral feeding, and length of hospital stay were compared. Blood bilirubin levels, white blood cell count, and C-reactive protein levels were monitored. Results The time to first stool and day of toleration to full oral feeding occurred significantly sooner, whereas nasogastric tube drainage duration and hospital stay were significantly shorter in the EEN-anastomosis group than in the C-anastomosis group. Time to first stool occurred significantly sooner in the EEN-laparotomy group than in the C-laparotomy group, although other parameters did not differ. Neither anastomotic leakage nor dehiscence was observed in any group. There were two cases of wound infection and two of exitus among patients in the C group. Conclusion Postoperative, early intragastric, small-volume breast milk feeding is well tolerated by newborns. It is a reliable and feasible approach in neonates even in the presence of an intestinal anastomosis after abdominal surgery.

7225 Enteroscopic treatment of early postoperative bowel obstruction.

Introduction: Early postoperative small bowel obstruction (EPSBO) occurs in nearly 1% of patients undergoing laparotomy and has a mortality rate exceeding 17%. Nasogastric (NG) decompression is successful in 78% of patients. Repeat laparotomy has been recommended when obstruction does not resolve after 14 days of NG decompression. We report 4 patients with EPSBO treated successfully with push enteroscopy after failed NG decompression. Methods: Four patients who failed NG decompression underwent push enteroscopy instead of repeat laparotomy. EPSBO was diagnosed if obstruction lasting more than 14 days developed after initial resolution of postoperative ileus or high NG output persisted postoperatively for 21 days in the absence of prolonged ileus or sepsis. Small bowel series or CT was utilized when radiographic assessment was necessary. The Olympus SIF 100 push enteroscope was introduced with an overtube using topical anesthesia and intravenous sedation. After maximal insertion, the enteroscope was withdrawn without evacuation of insufflated air. NG tubes were placed after enteroscopy, and the patients followed clinically. Flatus, defecation, and tolerance of diet defined resolution of EPSBO. Results: EPSBO resolved 24-36 hours following enteroscopy, and all patients were discharged on general diets 48 hours after return of bowel function. Readmission has not been necessary during 6-18 month followup. Conclusions: Our experience suggests that push enteroscopy is successful in treating EPSBO and should be considered prior to re-operation. Repeat laparotomy may not be necessary and push enteroscopy may reduce patient morbidity, cost, and hospital lengths of stay associated with this uncommon surgical complication.

Resolution of postoperative ileus in laparoscopic vs. open colectomy

Resolution of postoperative ileus in laparoscopic vs. open colectomy

Comparison of Patient-Controlled Analgesia Versus Intramuscular Narcotics in Resolution of Postoperative Ileus after Radical Retropubic Prostatectomy

Patient-controlled analgesia has become standard practice after major abdominal operations. The benefits of patient-controlled analgesia have been well documented. However, its possible effect of prolonging postoperative ileus has not been well examined. To determine if patient-controlled analgesia prolongs postoperative ileus when compared to conventional intramuscular narcotics, a retrospective review of length of postoperative ileus in 98 consecutive patients (62 using patient-controlled analgesia and 36 using intramuscular narcotics) undergoing bilateral pelvic lymphadenectomy and radical retropubic prostatectomy was done. The patients receiving patient-controlled analgesia resolved the postoperative ileus an average of 1.0day later than the intramuscular injection group (5.2 days versus 4.2 days p <0.0001). Overall hospital stay was not significantly affected. Our results show that patient-controlled analgesia use prolongs postoperative ileus.

Resolution of postoperative ileus in humans.

Bipolar electrodes were placed in the ascending and descending colon of 13 patients during laparotomy. The magnitude of their operations varied from exploratory laparotomy to total gastrectomy. The magnitude and length of the operations performed did not correlate positively with the duration of postoperative ileus. Signals were recorded for up to 4 hours daily for up to 8 days after operation during periods of rest and, in some patients, after administration of epidural or parenteral morphine sulfate. Power spectrum analyses of electrical control activity (ECA) showed dominant frequencies in both lower (2-9 cpm) and higher (9-14 cpm) ranges. During postoperative recovery, the mean ECA frequencies in right and left colon were relatively constant, but a variety of dominant ECA frequency relationships were observed. The modal pattern in the right colon was a shift in the dominant frequency from the higher to the lower range as recovery progressed, while the modal pattern in the left colon was persistent dominance of ECA in the higher frequency range. Electrical response activity (ERA) initially was comprised of only random, disorganized single bursts but became progressively more complex through the initial 3 postoperative days with the appearance of more organized bursts and clusters, some of which propagated very slowly (about 5 cm/min) both orad and aborad. ERA recovery culminated, typically on the third or fourth postoperative day, with the return of long bursts of continuous ERA, some of which propagated at a higher velocity (about 80 cm/min) and exclusively in the aborad direction and which were accompanied by passage of flatus or by defecation.