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Bowel SurgeryBowel SurgeryBy Louise ConstableBy Louise Constable
Aims and ObjectivesAims and ObjectivesRefresh knowledge of bowel anatomy
Increase awareness of common bowel pathology and procedures
Explore Case Study – Mrs P
Increase awareness of physiotherapist role post-op
Refresh knowledge of bowel anatomy
Increase awareness of common bowel pathology and procedures
Explore Case Study – Mrs P
Increase awareness of physiotherapist role post-op
IntroductionIntroduction In 2008/2009 1.3 million bowel procedures were
performed in the UK The colon is the structure most commonly
operated on The median length of stay for upper GI
procedures is 5 days The median length of stay for lower GI
procedures is 3 days Most emergency surgery results from pathology
of the duodenum (76%) and appendix (97%)http://www.hesonline.nhs.uk
In 2008/2009 1.3 million bowel procedures were performed in the UK
The colon is the structure most commonly operated on
The median length of stay for upper GI procedures is 5 days
The median length of stay for lower GI procedures is 3 days
Most emergency surgery results from pathology of the duodenum (76%) and appendix (97%)
http://www.hesonline.nhs.uk
Bowel AnatomyBowel Anatomy
Please draw these structures
StomachSmall bowel Large bowel
Caecum, appendix, colon, rectum
Please draw these structures
StomachSmall bowel Large bowel
Caecum, appendix, colon, rectum
Bowel AnatomyBowel Anatomy
Small IntestineSmall Intestine 3-7m long, 2.5-3 cm in diameter, 200m² surface
area Comprises of three structures: Duodenum,
Jejunum, Ileum Food passes into the small bowel from the
stomach via the phylorus Food is propelled through the small bowel by
wave-like muscular contractions - peristalsis Vast majority of digestion and absorption takes
place in the small bowel
3-7m long, 2.5-3 cm in diameter, 200m² surface area
Comprises of three structures: Duodenum, Jejunum, Ileum
Food passes into the small bowel from the stomach via the phylorus
Food is propelled through the small bowel by wave-like muscular contractions - peristalsis
Vast majority of digestion and absorption takes place in the small bowel
Large IntestineLarge Intestine 1.5m in length Receives faecal mater as liquid from the small
intestine Comprised of caecum, ascending colon,
transverse colon, descending colon, sigmoid colon, rectum
Responsible for reclaiming water, absorbing vitamins, combining indigestible matter with mucus and bacteria to make faeces
1.5m in length Receives faecal mater as liquid from the small
intestine Comprised of caecum, ascending colon,
transverse colon, descending colon, sigmoid colon, rectum
Responsible for reclaiming water, absorbing vitamins, combining indigestible matter with mucus and bacteria to make faeces
Common Bowel PathologyCommon Bowel Pathology Bowel obstruction Cancers/tumours Bowel perforation Diverticular disease/ diverticulitis Appendicitis Volvulus Crohn’s disease Ulcerative colitis Trauma
Bowel obstruction Cancers/tumours Bowel perforation Diverticular disease/ diverticulitis Appendicitis Volvulus Crohn’s disease Ulcerative colitis Trauma
Common Bowel ProceduresCommon Bowel Procedures Laparotomy Bowel decompression Hartman’s procedure Ileostomy/colostomy High/low anterior resection Hemicolectomy Appendectomy Small bowel resection Endoscopy
Laparotomy Bowel decompression Hartman’s procedure Ileostomy/colostomy High/low anterior resection Hemicolectomy Appendectomy Small bowel resection Endoscopy
Case Study – Mrs PCase Study – Mrs P 07.04.10 - 57 yr old lady admitted to hospital with
diarrhoea, vomiting and abdominal pain
PMH – Total abdominal hysterectomy, appendectomy, multiple operations for adhesions, small bowel resection
Multiple investigations – USS, AXR, FBCIdentified multiple adhesions of the small
bowel, bladder and pelvis
07.04.10 - 57 yr old lady admitted to hospital with diarrhoea, vomiting and abdominal pain
PMH – Total abdominal hysterectomy, appendectomy, multiple operations for adhesions, small bowel resection
Multiple investigations – USS, AXR, FBCIdentified multiple adhesions of the small
bowel, bladder and pelvis
Case Study – Mrs PCase Study – Mrs P Laparotomy – Adhesiolysis, small bowel
resection
Post-op complications – Anastomosis leak/breakdown, fluid collection in peritoneal cavity and gross faecal contamination
Returned to theatre – end ileostomy and mucus fistula
Laparotomy – Adhesiolysis, small bowel resection
Post-op complications – Anastomosis leak/breakdown, fluid collection in peritoneal cavity and gross faecal contamination
Returned to theatre – end ileostomy and mucus fistula
Case Study – Mrs PCase Study – Mrs P 4 months later – Excision of non-viable terminal
ileum, blind-loop caecum and ascending colon. Creation of hand-sewn anastomosis between ilium and mid transverse colon
Post-op complications – faecal contents passed out through wound (enterocutaneous fistula)
Pt now recovering well and has been eating and drinking for the first time in months
4 months later – Excision of non-viable terminal ileum, blind-loop caecum and ascending colon. Creation of hand-sewn anastomosis between ilium and mid transverse colon
Post-op complications – faecal contents passed out through wound (enterocutaneous fistula)
Pt now recovering well and has been eating and drinking for the first time in months
Physiotherapy InterventionPhysiotherapy Intervention
Post-op chest care Positioning, DBE’s, supported cough, circ.
ex’sEarly mobilisation
Sitting on edge of bed, bed to chair TF’sMobilisation
Use of walking aids to assist balanceIndependent mobilisation
Post-op chest care Positioning, DBE’s, supported cough, circ.
ex’sEarly mobilisation
Sitting on edge of bed, bed to chair TF’sMobilisation
Use of walking aids to assist balanceIndependent mobilisation
Evidence-Based PracticeEvidence-Based Practice
Pasquina et al (2006) – No evidence to support prophylactic respiratory physiotherapy post-op
Mackay et al (2005) – Investigated addition of DBE’s to early mobilization program – No significant difference between groups
Dureuil et al (1987) - Impairment of vital capacity and diaphragmatic index 1 week post-surgery upper abdominal surgery
Pasquina et al (2006) – No evidence to support prophylactic respiratory physiotherapy post-op
Mackay et al (2005) – Investigated addition of DBE’s to early mobilization program – No significant difference between groups
Dureuil et al (1987) - Impairment of vital capacity and diaphragmatic index 1 week post-surgery upper abdominal surgery
Evidence-Based PracticeEvidence-Based Practice Browning et al (2007) – Observational study
Activity milestonesActivity milestones Time spent uprightTime spent uprightDay 1 – Sit outDay 1 – Sit out Day 1 – 3 minsDay 1 – 3 minsDay 1.8 – Mobilise with aid/assistanceDay 1.8 – Mobilise with aid/assistance Day 2 – 7.6 minsDay 2 – 7.6 minsDay 6.3 – Mobilise independentlyDay 6.3 – Mobilise independently Day 3 – 13.2 minsDay 3 – 13.2 mins
Day 4 – 34.4 minsDay 4 – 34.4 mins
Basse et al (2002) identified accelerated post-operative recovery program improved pt outcomes with respect to lean body mass, pulmonary function & bowel function
Browning et al (2007) – Observational study
Activity milestonesActivity milestones Time spent uprightTime spent uprightDay 1 – Sit outDay 1 – Sit out Day 1 – 3 minsDay 1 – 3 minsDay 1.8 – Mobilise with aid/assistanceDay 1.8 – Mobilise with aid/assistance Day 2 – 7.6 minsDay 2 – 7.6 minsDay 6.3 – Mobilise independentlyDay 6.3 – Mobilise independently Day 3 – 13.2 minsDay 3 – 13.2 mins
Day 4 – 34.4 minsDay 4 – 34.4 mins
Basse et al (2002) identified accelerated post-operative recovery program improved pt outcomes with respect to lean body mass, pulmonary function & bowel function
ConclusionConclusion
Awareness of bowel anatomy very important!!
Many conditions require bowel surgeryBowel surgery is not always curative and
often people have multiple surgeriesEBP - Lots of support for early
mobilization however currently paucity of evidence supporting prophylactic chest PT
Awareness of bowel anatomy very important!!
Many conditions require bowel surgeryBowel surgery is not always curative and
often people have multiple surgeriesEBP - Lots of support for early
mobilization however currently paucity of evidence supporting prophylactic chest PT
ReferencesReferencesKumar, P. & Clark, M. (1998). Clinical Medicine. W.B Saunders: London
Pasquina, P., Tramer, M., Granier, J. & Walder, B. (2006). Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery. Chest, 130(6), 1887-1899
Mackay, M., Ellis, E. & Johnson, C. (2005). Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients. Australian Journal of Physiotherapy, 51, 151-159
Browning, L., Denehy, L. & Scholes, R. (2007). The quantity of early upright mobilisation performed following upper abdominal surgery is low: An observational study. Australian Journal of Physiotherapy, 53, 47-52
Basse, L., Raskov, H., Hjort Jakobsen, P., Sonne, E., Billesbolle, P., Hendel, H., Rosenberg, J. & Kehlet, H. (2002). Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. British Journal of Surgery, 89(4), 446-453
Dureuil, B., Cantineau, J. & Desmonts, J. (1987). Effects of upper or lower abdominal surgery on diaphragmatic function. British Journal of Anaesthesia, 59(10), 1230-1235
http://www.hesonline.nhs.uk
Kumar, P. & Clark, M. (1998). Clinical Medicine. W.B Saunders: London
Pasquina, P., Tramer, M., Granier, J. & Walder, B. (2006). Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery. Chest, 130(6), 1887-1899
Mackay, M., Ellis, E. & Johnson, C. (2005). Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients. Australian Journal of Physiotherapy, 51, 151-159
Browning, L., Denehy, L. & Scholes, R. (2007). The quantity of early upright mobilisation performed following upper abdominal surgery is low: An observational study. Australian Journal of Physiotherapy, 53, 47-52
Basse, L., Raskov, H., Hjort Jakobsen, P., Sonne, E., Billesbolle, P., Hendel, H., Rosenberg, J. & Kehlet, H. (2002). Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition. British Journal of Surgery, 89(4), 446-453
Dureuil, B., Cantineau, J. & Desmonts, J. (1987). Effects of upper or lower abdominal surgery on diaphragmatic function. British Journal of Anaesthesia, 59(10), 1230-1235
http://www.hesonline.nhs.uk
