A Puzzling Case of Prolonged Post-op Ileus s/p Total Abdominal Hysterectomy

Adam L. Johnson 2/3/16

Case

• Ms. CC is a 52 yo G3P3 POD4 s/p TAH, BSO for b/l ovarian masses who presents to the ED for 2 days of worsening N/V. Pt is vomiting stomach contents, worsened by foods and liquids, associated with abdominal pain and myalgias. Patient denies fevers, chills, cough, diarrhea

• PMHx: Insomnia, ADD • PSHx: Bladder suspension, Tubal ligation, Colonoscopy• Allergies: Bactrim-Rash• Meds: Nortriptyline • PE: Pulse 133. Abdominal exam: she exhibits distension,

diffuse tenderness to palpation. Rest of PE wnl

Post-op Ileus (POI)• POI- Refers to obstipation and intolerance of oral

intake following abdominal or nonabdominal surgery.

• Non-mechanical factors-Inflammation of intestinal smooth muscle

• Post-op ileus-normal, obligatory and physiologic response to abdominal surgery

• Prolonged postoperative ileus->3-5 days absent bowel activity

Luckey A, Livingston E, Tache Y, Mechanisms and Treatment of Posteroperative Ileus 2003

Learning Objectives

• To examine a study describing the mean onset of various bowel recovery checkpoints s/p TAH.

• To recall common risk factors of Post-op ileus and explore obesity’s role in the incidence of POI after TAH

• To examine differences in incidences of POI after TAH, LAVH and TVH.

• To determine the efficacy of alternative methods in treatment of POI

• To take a closer look into the patient’s medical history observing factors plausibly contributing to POI.

Mean Time of Bowel Recovery Checkpoints after TAH

• Placebo arm of double blind study

• 140 TAH Patients• 3 Check points • Provided standardized

timeline for expected bowel recovery

Wolff B, Viscusi E, Delaney C, Du W, Techner L Patterns of GI Recovery after Bowel Resection and Total Abdominal Hysterectomy: Pooled results from the Placebo Arms of Alvimopan phase III North American Trials: Journal of American College of Surgeons, Volume 205 (1)-July, 2007

GI-3recovery

GI-2 recovery

DCOWritten

Mean hrs

69.5 hrs 115.3hrs 79.9 hrs

Prolonged Postoperative Ileus, Definition, Risk Factors, and Predictors after Surgery

• Retrospective Study• 88 patients • Estimate Blood Loss

(EBL) and and Total Opiate Dose TOD)

• EBL and TOD shown to be strong risk factors

• Weakness: Study limited in its ability to produce cause-effect relationships and to control for all possible confounders.

Avo A, Nunoo-Mensah J, Swama B, Gauderman J, Essani R Prolonged Postoperative Ileus, Definition, Risk Factors, and Predictors after Surgery Volume 32 (7)-Jul 1, 2008

Obesity’s Contribution to POI s/p TAH

• Retrospective study• 357 women – 172 Obese (82.5% African-American)– 185 Non-obese women (70% African-American)

• Non-obese women had a significantly higher incidence of ileus (13.5% vs 6.4, p<0.05)

• Disproportionate representation of African-American

Harmanli O, Dandulu V, Lidicker J, Ayaz R, Panganamamula U, Isik E The Effect of Obesity on Total Abdominal Hysterectomy, Journal of Women’s Health Vol 19 November 10, 2010

Obese BMI > 30kg/m2(n=172) n (%)

NonObese BMI< 30kg/m2(n=185)

Ileus 11 (6.4) 25 (13.5)

Incidence of POI s/p TAH vs TVH

TAH TAH TVH TVH

Time periods

Period A+B (n=34)

Period C (n=12)

Period A+B (n=12)

Period C (n=3)

Ileus 3 1 0 0

• Retrospective study over 3 time periods

• 4213 pts– 3220 pts TAH– 993 pts TVH

• Time Periods – Period A: 1976-1983– Period B: 1984-1991– Period C 1994-1997

• Disproportionate sample size

Salamalekis E, Sykiotis C, Conidaris S, Bettas P, Loghis C, Length of Patient Hospitalization after Abdominal and Vaginal Hysterectomy, Journal of Gynecologic Surgery, Volume 15, Number 4 1999

Incidence of POI s/p TAH vs. LAVH

• Retrospective Study• 126 pts – 61 LAVH– 65 TAH

• Gynecologist performed all the surgeries

Arbogast J, Welch R, Riza E, Ricautre E, Pieper D Laparoscopically assisted vaginal hysterectomy appears to be an alternative to total abdominal hysterectomy, Journal of Laparoendoscopic Surgery, Volume 4, Number 3, 1994

LAVH TAH P value

Ileus 0 2 NS

Acupuncture as an Alternative Prevention Strategy for PPOI

• Randomized Acupuncture vs. Usual Care• 85 patients – 44 pts received acupuncture– 41 pts usual care

• Acupuncture no affect on PPOI

Meng Z, Garcia M, Chiang J, Peng H, Shi Y, Electroacupuncture to prevent prolonged postoperative ileus: A randomized clinical trial, World Journal of Gastroenterology, Jan 2010

Nortriptyline: Causative Agent of Ileus

• Case Study 1• 14 1/2 yo woman • Nortriptyline 75 mg• 12 days

• Case Study 3• 81 yo women • Nortriptyline 25mg TID• 2 days

Ellis A, Bigmoid B, Faulker G, Cohen A, Adynamic Ileus and Nortriptyline, Brit med J, 841-842 1966

• Case Study 2• 27 yo woman • Nortriptyline 25mg TID• 8 days

• All women developed ileus

• All regained bowel function after discontinuation

Case Wrap-up • Ms. CC is a 52 yo G3P3 HD#17/POD#21 s/p TAH, BSO

with pathology consistent with Meig’s syndrome readmitted for treatment of post-op ileus vs. SBO.

• NGT placed day of admission• HD#6/POD#10 TPN started• HD#8/ POD#12 SBFT-studies showed contrast in the

Colon and rectum • HD#9/POD 13- KUB showed minimal contrast in the

small bowel , distal colon, and rectum w/ non-obstructive pattern

Ms. CC KUB 1/11/16

Enteric tube terminates in the distal stomach. Interval decrease in amount of contrast visualized. minimal contrast in the small bowel , distal colon, and rectum w/ non-obstructive pattern

Case Wrap-up

• Continued conservative management• HD#20/POD#24-Paracentesis• HD#22/POD#26-Colonoscopy. Incomplete due

to incomplete bowel prep. Cultures NGx2 days• Surgery, Gastroenterology, Rheumatology

have all been consulted…STILL PUZZLED!

References• Wolff B, Viscusi E, Delaney C, Du W, Techner L Patterns of GI Recovery after Bowel Resection

and Total Abdominal Hysterectomy: Pooled results from the Placebo Arms of Alvimopan phase III North American Trials: Journal of American College of Surgeons, Volume 205 (1)-July, 2007

• Avo A, Nunoo-Mensah J, Swama B, Gauderman J, Essani R Prolonged Postoperative Ileus, Definition, Risk Factors, and Predictors after Surgery Volume 32 (7)-Jul 1, 2008

• Harmanli O, Dandulu V, Lidicker J, Ayaz R, Panganamamula U, Isik E The Effect of Obesity on Total Abdominal Hysterectomy, Journal of Women’s Health Vol 19 November 10, 2010

• Salamalekis E, Sykiotis C, Conidaris S, Bettas P, Loghis C, Length of Patient Hospitalization after Abdominal and Vaginal Hysterectomy, Journal of Gynecologic Surgery, Volume 15, Number 4 1999

• Arbogast J, Welch R, Riza E, Ricautre E, Pieper D Laparoscopically assisted vaginal hysterectomy appears to be an alternative to total abdominal hysterectomy, Journal of Laparoendoscopic Surgery, Volume 4, Number 3, 1994

• Meng Z, Garcia M, Chiang J, Peng H, Shi Y, Electroacupuncture to prevent prolonged postoperative ileus: A randomized clinical trial, World Journal of Gastroenterology, Jan 2010

• Ellis A, Bigmoid B, Faulker G, Cohen A, Adynamic Ileus and Nortriptyline, Brit med J, 841-842 1966

https://www.youtube.com/watch?v=XxcfYiTLtYU

The role Magnesium oxide + Disodium phosphate shortening time of POI s/p TAH

• Double-blind, placebo-controlled

• Patients 53– Placebo 27 pts– Laxative 26 pts

• Laxatives improves recovery of GI Function:reduced median time to 1st defecation with 24 hrs

Laxative Placebo P

Median time

45 hrs 69 hrs P=<.0001

Hansen C, Sorensen M, Moller C, Ottensen B, Kehlet H, Effect of laxatives on gastrointestinal functional recovery in fast-track hysterectomy: a double blind, placebo-controlled randomized study American Journal of Obstetrics and Gynecology, Volume 196 (4) Apr 1, 2007

Considering Mu-Receptor Antagonist role in decreasing POI s/p TAH while measuring

• Double-blind, randomized placebo controlled • 519 women (randomized 4:1)• Alvimopan accelerated – 413 pts Alvimopan– 106 pts Placebo

Herzog T, Coleman R, Guerrieri J, Gabriel K, Du W, Techner L, Fort J, Wallin B, A Double-blind, randomized placebo-controlled phase III study of the safety of the alvimopan in patients who undergo simple total abdominal hysterectomy , American Journal of Obstetrics and Gynecology, Volume 195 (2) Aug 1, 2006