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Management of ileus and small-bowel obstruction following benign gynecologic surgery
International Journal of Gynecology and Obstetrics 121 (2013) 56–59
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Management of ileus and small-bowel obstruction following benign gynecologic surgery Arielle M. Allen a,⁎, Danielle D. Antosh b, Cara L. Grimes c, Catrina C. Crisp d, Aimee L. Smith e, Sarah Friedman f, Brook L. Mcfadden g, Robert E. Gutman b, Rebecca G. Rogers g a
Division of Female Pelvic Medicine and Reconstructive Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, USA Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, MedStar Washington Hospital Center, Washington, USA Department of Reproductive Medicine, Division of Female Pelvic Medicine and Reconstructive Surgery, University of California, San Diego, USA d Division of Urogynecology and Reconstructive Pelvic Surgery, Good Samaritan Hospital, Cincinnati, USA e Division of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston, USA f Division of Urogynecology and Reconstructive Pelvic Surgery, Johns Hopkins University/Greater Baltimore Medical Center, Baltimore, USA g Division of Urogynecology, University of New Mexico Health Sciences Center, Albuquerque, USA b c
a r t i c l e
i n f o
Article history: Received 7 June 2012 Received in revised form 8 November 2012 Accepted 18 December 2012 Keywords: Gynecology Management of bowel obstruction Management of ileus Surgery
a b s t r a c t Objective: To describe practice preferences for the diagnosis and management of ileus and small-bowel obstruction (SBO) following benign gynecologic surgery. Methods: A secondary descriptive analysis was performed on data from a multicenter case–control study of patients who underwent gynecologic surgery and subsequently developed ileus or SBO. Information was collected regarding interventions such as type of imaging ordered for diagnosis, diet alterations, antiemetic administration, and need for reoperation. Results: In total, 144 cases were identified. Abdominal X-ray was the most common imaging modality, occurring in 54 (37.5%) cases. Sixty-nine (65.1%) of the 106 women who underwent imaging were given definitive radiologic diagnoses of either ileus (50 [72.5%]) or SBO (19 [27.5%]); 57.9% (n=11) of the SBO diagnoses and 90.0% (n=45) of the ileus diagnoses were managed conservatively. Eighteen (12.5%) patients underwent reoperation for bowel obstruction. There were no significant differences in rate of reoperation between cases involving the use of single antiemetics and those involving the use of multiple antiemetics (P=0.18), or between diet statuses on postoperative day 1 (P =0.08). Conclusion: Most study centers initially performed an abdominal X-ray for diagnostic purposes. The majority used a multimodal treatment approach. None of the management options decreased the likelihood of reoperation. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Ileus and small-bowel obstruction (SBO) symptoms—which are caused by an alteration in bowel function—include nausea, vomiting, abdominal distention, and discomfort. Postoperative ileus and SBO place significant burdens on patients and the healthcare system by prolonging hospital stay, thereby increasing hospital and healthcare costs [1–3]. Despite this burden, there is limited evidence regarding treatment and prevention strategies for postoperative ileus and SBO following gynecologic surgery. Ileus and SBO often present similarly, and are primarily managed conservatively. Imaging is often used to differentiate between a focal bowel obstruction and a generalized slowing or delay of bowel function associated with ileus. However, there is no standardized definition of ileus and it may be difficult to distinguish between this condition and ⁎ Corresponding author at: Division of Female Pelvic Medicine and Reconstructive Surgery, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd, WP2430, Oklahoma City, OK 73104, USA. Tel.: +1 405 271 5597; fax: +1 405 271 1655. E-mail address: [email protected] (A.M. Allen).
SBO radiologically. Treatment may involve nasogastric decompression, diet reversal for symptom relief, hydration, antiemetics, and restoring electrolyte balance [4–6]. Some patients need reoperation when these conservative measures fail. Although there are various therapies available, it is unclear which are used most often and which are most effective in patients with ileus or SBO after gynecologic surgery. The aim of the present study was to describe practice patterns among gynecologists for diagnosing and treating postoperative ileus and SBO following benign gynecologic surgery. 2. Materials and methods A secondary analysis was conducted on data from an as-yetunpublished multicenter case–control study conducted through the Fellows' Pelvic Research Network at 7 academic teaching hospitals (in Oklahoma City, OK; Washington DC; San Diego, CA; Cincinnati, OH; Weston, FL; Baltimore, MD; and Albuquerque, NM) in the USA from January 1, 2005, to June 30, 2010. The primary study aimed to identify risk factors leading to clinically significant postoperative ileus/SBO in a population of women undergoing a variety of gynecologic
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.11.009
A.M. Allen et al. / International Journal of Gynecology and Obstetrics 121 (2013) 56–59
surgical procedures. It involved the identification of case patients who underwent benign gynecologic surgery and subsequently developed ileus or SBO. Each case was then matched to 2 control women who underwent the same benign gynecologic procedure closest in time period at the same institution but did not develop SBO or ileus. The present study assessed data from the case patients only, describing the postoperative management of these women. Similar to a previous study, cases of ileus and SBO were grouped together owing to their similar clinical presentation and were defined as any symptoms of nausea, vomiting, abdominal pain, and/or abdominal distention resulting in a prolongation of stay during index hospitalization (≥2 days for laparoscopic or vaginal surgery; ≥4 days for abdominal surgery), readmission, or reoperation within 1 year [7]. After Institutional Review Board (IRB) approval was obtained at each site, cases were identified using Current Procedural Terminology (American Medical Association, Chicago, IL, USA) codes for benign gynecologic surgeries and International Classification of Diseases, 9th Revision [8] codes for ileus, nausea, vomiting, and bowel obstruction. In-patient charts were reviewed for intraoperative and postoperative data. Type of imaging ordered for diagnosis, changes in diet ordered, antiemetic administration, and need for reoperation were recorded. Descriptive statistics and bivariate associations were reported regarding practice preferences at the participating institutions with regard to the diagnosis and postoperative management of ileus and SBO. The supervising IRBs for each participating institution did not require informed consent. Statistical analysis was performed using Stata/IC 11 (StataCorp, College Station, TX, USA). Statistical comparisons were performed using conditional logistic regressions for binary outcomes and Mantel–Haenszel tests for continuous/ordinal outcomes. Odds ratios with 95% confidence intervals and P values below 0.05 were used to determine statistical significance. 3. Results Seven academic institutions from geographically diverse areas of the USA provided information regarding management practices for a total of 144 cases that met inclusion criteria for postoperative ileus or SBO following benign gynecologic surgery. All participating institutions were academic teaching hospitals and ranged in size
Institution 1
n=31
Institution 2 n=17
Institution 3 n=18
57
from a 300-bed hospital to a larger medical complex with more than 1000 beds. In 85 (59.0%) cases, the patient developed ileus during index admission, and in 54 (37.5%) cases the woman was readmitted for ileus or SBO. Five (3.5%) patients were diagnosed with ileus or SBO during index admission and were subsequently readmitted for the same diagnosis. In 18 (12.5%) cases, the patient underwent reoperation for bowel obstruction. When made during the index admission, the diagnosis of ileus or SBO occurred within a median time of 2 postoperative days (range, 0–7 days). For patients who were readmitted, the median time to diagnosis was 8 postoperative days (range, 1–358 days). For patients who underwent reoperation, the median time from index surgery to reoperation was 11 days (range, 5–316 days). Fig. 1 demonstrates the outcome of cases. Use of imaging varied among the cases of ileus and SBO. Abdominal X-ray alone was the most common imaging modality—occurring in 54 (37.5%) cases—followed by abdominal X-ray plus computed tomography (CT) in 30 (20.8%) cases, CT alone in 19 (13.2%) cases, and other forms of imaging in 3 (2.1%) cases. Thirty-eight (26.4%) patients did not undergo imaging and were diagnosed based solely on symptomatology and physical examination. Of note, there was no statistically significant difference in time to resolution of symptoms between women diagnosed via imaging of any form and those who underwent no imaging: 4.7 days versus 11.7 days (P = 0.46). Of the 106 women who underwent any form of imaging, 69 (65.1%) received definitive radiologic diagnoses of either ileus (50 [72.5%]) or SBO (19 [27.5%]). The imaging results of the remaining patients did not provide definitive diagnoses, and multiple findings were listed such as “partial SBO, cannot rule out ileus” or “air/fluid levels, may be ileus versus SBO.” Of the women with definitive radiologic diagnoses, 57.9% (n = 11) with SBO diagnoses and 90.0% (n = 45) with ileus diagnoses were managed conservatively, without the need for readmission or reoperation. Fifteen (83.3%) of the 18 patients who underwent reoperation for SBO were diagnosed with partial SBO or SBO on imaging. Bivariate analysis between the rate of reoperation and the imaging results revealed that patients with a diagnosis of SBO on imaging were more likely to undergo reoperation than those diagnosed with ileus on imaging (42.1% vs 10.0%; P = 0.002). Furthermore, the odds of reoperation decreased by a factor of 0.15 (85%) for those with imaging results listed as ileus (95% confidence interval, 0.04–0.56).
Institution 4 n=20
Institution 5 n=15
Institution 6 n=20
Total cases n=144
Dx during index admission n=90
Readmitted for Dx of SBO/ileus n=59
Dx during index admission AND readmitted n=5 Fig. 1. Flowchart of patient outcomes.
Reoperation n=1
Reoperation n=14
Reoperation during readmission n=3
Institution 7 n=23
58
A.M. Allen et al. / International Journal of Gynecology and Obstetrics 121 (2013) 56–59 Table 1 Management of ileus or SBO.a Antiemeticb
Cases (n = 136)c
None Promethazine Metoclopramide Ondansetron Compazine Combination therapy Managementb No intervention Diet reversal NPO NGT Taken to OR
23 (16.9) 61 (44.9) 49 (36.0) 87 (64.0) 6 (4.4) 72 (52.9) 3 (2.2) 23 (16.9) 88 (64.7%) 53 (39.0%) 18 (13.2)
Abbreviations: NGT, nasogastric tube; NPO, nil per os; OR, operating room; SBO, small-bowel obstruction. a Values are given as number (percentage). b Result categories overlap. c Management data unavailable for entire cohort.
The management of ileus and SBO varied (Table 1). Of the 136 women for whom these data were available, 72 (52.9%) received a multi-agent antiemetic regimen upon diagnosis of SBO or ileus, whereas 23 (16.9%) received no antiemetics. Ondansetron was the most commonly administered antiemetic (87 [64.0%] patients). Promethazine (61 [44.9%]) and metoclopramide (49 [36.0%]) were also commonly ordered. Seventy-six (52.8%) patients underwent multimodal management for ileus/SBO, comprising diet regression or continuation of nil per os (NPO) status, placement of a nasogastric tube (NGT), administration of antiemetics, and/or reoperation. Mean time to ileus/SBO resolution was 4 ± 5 days. Resolution was defined by the return of bowel function (tolerating a regular diet without nausea and vomiting). Several management variables were analyzed to identify any correlation between time to resolution and form of management. The cases were divided into 2 groups: resolution of ileus/SBO within 3 days and resolution after 3 days. The variables analyzed included type of antiemetic medication administered and whether a single agent was used versus multiple agents; diet reversal; NGT placement; or a combination of these. Multivariate regression analysis revealed no evidence of a correlation between single versus multiple antiemetics or type of antiemetic and time to resolution of ileus. It also revealed no significant difference in time to resolution between cases in which patients underwent multimodal management and those in which single management (e.g. NGT only or diet reversal only) was used. An additional bivariate analysis was performed to investigate whether there was an association between management modality— with regard to type of antiemetic(s) used, diet administered on postoperative day 1, and NGT placement upon diagnosis—and odds of reoperation. There were no significant differences in rate of reoperation between cases involving the use of single antiemetics and those involving the use of multiple antiemetics (P = 0.18), or between diet statuses (NPO or clear liquids) on postoperative day 1 (P = 0.08). Only 2 patients for whom an NGT was placed underwent reoperation, which prevented adequate statistical analysis. 4. Discussion The present study analyzed practice patterns at 7 academic centers with regard to the diagnosis and management of postoperative ileus/ SBO after benign gynecologic surgery. Diagnostic imaging studies were frequently ordered (73.6%), and abdominal X-ray was the most commonly ordered imaging study, followed by CT. A published survey of gynecologic surgeons revealed similar preferences for imaging modalities for diagnosis of ileus and SBO [9]. Physicians order imaging studies in an attempt to differentiate ileus from bowel obstruction, which may require reoperation. Although abdominal
X-ray is commonly used as a first-line imaging test, previous studies have proven that abdominal CT is more sensitive and specific for differentiating ileus from SBO [6,10,11]. Another study evaluated postoperative imaging in patients with ileus/SBO after benign and gynecologic oncology surgeries; the authors reported that abdominal X-rays had little use in management [12]. Furthermore, there was no correlation in that study between X-ray diagnosis of either ileus or bowel obstruction and the need for reoperation. In the present study, imaging did not always differentiate ileus from SBO; however, patients with a definitive diagnosis of SBO on imaging (whether abdominal X-ray or CT) were more likely to require reoperation compared with those diagnosed with ileus. The present study demonstrated that the majority of centers chose to follow a multimodal approach for the treatment of ileus and SBO. This included the use of multiple antiemetics, diet regression or continuation of NPO status, NGT placement, and/or reoperation. Despite this multimodal approach, none of the management options seemed to decrease the odds of reoperation. The overall rate of reoperation (12.5%) for ileus/SBO was similar to that in previous reports. Heinberg et al. [12] reported a reoperation rate of 8.3% among gynecologic oncology patients diagnosed with ileus/SBO after surgery; most of those patients were treated with multimodal conservative therapies. Several studies indicate that preventive measures such as early postoperative feeding, gum chewing, bowel stimulation, and use of alvimopan and ketorolac may decrease the incidence of postoperative ileus [4]. In fact, early postoperative feeding has been shown to decrease ileus following cesarean delivery under regional anesthesia [13,14] and major gynecologic surgery [15]. Gum chewing has been shown to decrease the incidence of postoperative ileus after colorectal surgery [16] and lead to rapid resumption of intestinal motility and shorter hospital stay after cesarean delivery under general anesthesia [17]. The present analysis did not identify any factors that decreased time to resolution of ileus/SBO. Furthermore, it did not ascertain whether the various management options were used to prevent the onset of ileus/SBO symptoms or to treat symptoms of an underlying pathophysiologic process. The strengths of the study included its multicenter nature, which incorporated different diagnosis and postoperative management styles. It is likely that this reflects more closely the true management strategies of gynecologists throughout the USA. The limitations of the study were related to the retrospective design, including incomplete documentation and variance in the quality of information recorded. In abstracting information from in-patient charts, it is possible that not all management options were captured and included in the analysis. Furthermore, data regarding management options such as gum chewing or ketorolac use were not specifically collected. Data regarding alvimopan use were collected; however, its infrequent usage prevented analysis. In addition, owing to similar clinical presentation and initial management, cases of ileus and SBO were grouped together in the present analysis. It is possible that these diagnoses should not be grouped together because of different pathophysiologic mechanisms of disease. A larger study involving more academic centers would be required to perform an independent analysis of ileus and SBO. In conclusion, most academic centers used abdominal X-ray to diagnose ileus and SBO after benign gynecologic surgery, despite evidence that that CT might be a better discriminatory modality for differentiating the conditions. Most centers used a multimodal approach to the management of ileus and SBO. The present analysis did not identify any management strategy that decreased the time to resolution of ileus or SBO. Acknowledgments The study was supported by the Fellows' Pelvic Research Network (sponsored by the Society of Gynecologic Surgeons). Biostatistical
A.M. Allen et al. / International Journal of Gynecology and Obstetrics 121 (2013) 56–59
support for the project was funded in part by Federal funds (grant No. UL1RR031975) from the National Center for Research Resources and National Institutes of Health, through the Clinical and Translational Science Awards Program. Conflict of interest The authors have no conflicts of interest. References [1] Prasad M, Matthews JB. Deflating postoperative ileus. Gastroenterology 1999;117(2): 489–92. [2] Iyer S, Saunders WB, Stemkowski S. Economic burden of postoperative ileus associated with colectomy in the United States. J Manag Care Pharm 2009;15(6):485–94. [3] Luckey A, Livingston E, Taché Y. Mechanisms and treatment of postoperative ileus. Arch Surg 2003;138(2):206–14. [4] Fanning J, Valea FA. Perioperative bowel management for gynecologic surgery. Am J Obstet Gynecol 2011;205(4):309–14. [5] Livingston EH, Passaro Jr EP. Postoperative ileus. Dig Dis Sci 1990;35(1):121–32. [6] Sajja SB, Schein M. Early postoperative small bowel obstruction. Br J Surg 2004;91(6): 683–91. [7] Whitehead WE, Bradley CS, Brown MB, Brubaker L, Gutman RE, Varner RE, et al. Gastrointestinal complications following abdominal sacrocolpopexy for advanced pelvic organ prolapse. Am J Obstet Gynecol 2007;197(1):78.e1–7.
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[8] US Department of Health and Human Services, Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). 9th edition.; 10-2005. [9] Milad MP, Escobar JC, Sanders W. Partial small bowel obstruction and ileus following gynecologic laparoscopy. J Minim Invasive Gynecol 2007;14(1):64–7. [10] Frager DH, Baer JW, Rothpearl A, Bossart PA. Distinction between postoperative ileus and mechanical small-bowel obstruction: value of CT compared with clinical and other radiographic findings. AJR Am J Roentgenol 1995;164(4):891–4. [11] Frykberg ER, Phillips JW. Obstruction of the small bowel in the early postoperative period. South Med J 1989;82(2):169–73. [12] Heinberg EM, Finan MA, Chambers RB, Bazzett LB, Kline RC. Postoperative ileus on a gynecologic oncology service–do abdominal X-rays have a role? Gynecol Oncol 2003;90(1):158–62. [13] Göçmen A, Göçmen M, Saraoğlu M. Early post-operative feeding after caesarean delivery. J Int Med Res 2002;30(5):506–11. [14] Chantarasorn V, Tannirandorn Y. A comparative study of early postoperative feeding versus conventional feeding for patients undergoing cesarean section; a randomized controlled trial. J Med Assoc Thai 2006;89(Suppl. 4):S11–6. [15] MacMillan SL, Kammerer-Doak D, Rogers RG, Parker KM. Early feeding and the incidence of gastrointestinal symptoms after major gynecologic surgery. Obstet Gynecol 2000;96(4):604–8. [16] Noble EJ, Harris R, Hosie KB, Thomas S, Lewis SJ. Gum chewing reduces postoperative ileus? A systematic review and meta-analysis. Int J Surg 2009;7(2): 100–5. [17] Abd-El-Maeboud KH, Ibrahim MI, Shalaby DA, Fikry MF. Gum chewing stimulates early return of bowel motility after caesarean section. BJOG 2009;116(10):1334–9.
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
Management of ileus and small-bowel obstruction following benign gynecologic surgery Arielle M. Allen a,⁎, Danielle D. Antosh b, Cara L. Grimes c, Catrina C. Crisp d, Aimee L. Smith e, Sarah Friedman f, Brook L. Mcfadden g, Robert E. Gutman b, Rebecca G. Rogers g a
Division of Female Pelvic Medicine and Reconstructive Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, USA Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, MedStar Washington Hospital Center, Washington, USA Department of Reproductive Medicine, Division of Female Pelvic Medicine and Reconstructive Surgery, University of California, San Diego, USA d Division of Urogynecology and Reconstructive Pelvic Surgery, Good Samaritan Hospital, Cincinnati, USA e Division of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston, USA f Division of Urogynecology and Reconstructive Pelvic Surgery, Johns Hopkins University/Greater Baltimore Medical Center, Baltimore, USA g Division of Urogynecology, University of New Mexico Health Sciences Center, Albuquerque, USA b c
a r t i c l e
i n f o
Article history: Received 7 June 2012 Received in revised form 8 November 2012 Accepted 18 December 2012 Keywords: Gynecology Management of bowel obstruction Management of ileus Surgery
a b s t r a c t Objective: To describe practice preferences for the diagnosis and management of ileus and small-bowel obstruction (SBO) following benign gynecologic surgery. Methods: A secondary descriptive analysis was performed on data from a multicenter case–control study of patients who underwent gynecologic surgery and subsequently developed ileus or SBO. Information was collected regarding interventions such as type of imaging ordered for diagnosis, diet alterations, antiemetic administration, and need for reoperation. Results: In total, 144 cases were identified. Abdominal X-ray was the most common imaging modality, occurring in 54 (37.5%) cases. Sixty-nine (65.1%) of the 106 women who underwent imaging were given definitive radiologic diagnoses of either ileus (50 [72.5%]) or SBO (19 [27.5%]); 57.9% (n=11) of the SBO diagnoses and 90.0% (n=45) of the ileus diagnoses were managed conservatively. Eighteen (12.5%) patients underwent reoperation for bowel obstruction. There were no significant differences in rate of reoperation between cases involving the use of single antiemetics and those involving the use of multiple antiemetics (P=0.18), or between diet statuses on postoperative day 1 (P =0.08). Conclusion: Most study centers initially performed an abdominal X-ray for diagnostic purposes. The majority used a multimodal treatment approach. None of the management options decreased the likelihood of reoperation. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction Ileus and small-bowel obstruction (SBO) symptoms—which are caused by an alteration in bowel function—include nausea, vomiting, abdominal distention, and discomfort. Postoperative ileus and SBO place significant burdens on patients and the healthcare system by prolonging hospital stay, thereby increasing hospital and healthcare costs [1–3]. Despite this burden, there is limited evidence regarding treatment and prevention strategies for postoperative ileus and SBO following gynecologic surgery. Ileus and SBO often present similarly, and are primarily managed conservatively. Imaging is often used to differentiate between a focal bowel obstruction and a generalized slowing or delay of bowel function associated with ileus. However, there is no standardized definition of ileus and it may be difficult to distinguish between this condition and ⁎ Corresponding author at: Division of Female Pelvic Medicine and Reconstructive Surgery, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Blvd, WP2430, Oklahoma City, OK 73104, USA. Tel.: +1 405 271 5597; fax: +1 405 271 1655. E-mail address: [email protected] (A.M. Allen).
SBO radiologically. Treatment may involve nasogastric decompression, diet reversal for symptom relief, hydration, antiemetics, and restoring electrolyte balance [4–6]. Some patients need reoperation when these conservative measures fail. Although there are various therapies available, it is unclear which are used most often and which are most effective in patients with ileus or SBO after gynecologic surgery. The aim of the present study was to describe practice patterns among gynecologists for diagnosing and treating postoperative ileus and SBO following benign gynecologic surgery. 2. Materials and methods A secondary analysis was conducted on data from an as-yetunpublished multicenter case–control study conducted through the Fellows' Pelvic Research Network at 7 academic teaching hospitals (in Oklahoma City, OK; Washington DC; San Diego, CA; Cincinnati, OH; Weston, FL; Baltimore, MD; and Albuquerque, NM) in the USA from January 1, 2005, to June 30, 2010. The primary study aimed to identify risk factors leading to clinically significant postoperative ileus/SBO in a population of women undergoing a variety of gynecologic
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.11.009
A.M. Allen et al. / International Journal of Gynecology and Obstetrics 121 (2013) 56–59
surgical procedures. It involved the identification of case patients who underwent benign gynecologic surgery and subsequently developed ileus or SBO. Each case was then matched to 2 control women who underwent the same benign gynecologic procedure closest in time period at the same institution but did not develop SBO or ileus. The present study assessed data from the case patients only, describing the postoperative management of these women. Similar to a previous study, cases of ileus and SBO were grouped together owing to their similar clinical presentation and were defined as any symptoms of nausea, vomiting, abdominal pain, and/or abdominal distention resulting in a prolongation of stay during index hospitalization (≥2 days for laparoscopic or vaginal surgery; ≥4 days for abdominal surgery), readmission, or reoperation within 1 year [7]. After Institutional Review Board (IRB) approval was obtained at each site, cases were identified using Current Procedural Terminology (American Medical Association, Chicago, IL, USA) codes for benign gynecologic surgeries and International Classification of Diseases, 9th Revision [8] codes for ileus, nausea, vomiting, and bowel obstruction. In-patient charts were reviewed for intraoperative and postoperative data. Type of imaging ordered for diagnosis, changes in diet ordered, antiemetic administration, and need for reoperation were recorded. Descriptive statistics and bivariate associations were reported regarding practice preferences at the participating institutions with regard to the diagnosis and postoperative management of ileus and SBO. The supervising IRBs for each participating institution did not require informed consent. Statistical analysis was performed using Stata/IC 11 (StataCorp, College Station, TX, USA). Statistical comparisons were performed using conditional logistic regressions for binary outcomes and Mantel–Haenszel tests for continuous/ordinal outcomes. Odds ratios with 95% confidence intervals and P values below 0.05 were used to determine statistical significance. 3. Results Seven academic institutions from geographically diverse areas of the USA provided information regarding management practices for a total of 144 cases that met inclusion criteria for postoperative ileus or SBO following benign gynecologic surgery. All participating institutions were academic teaching hospitals and ranged in size
Institution 1
n=31
Institution 2 n=17
Institution 3 n=18
57
from a 300-bed hospital to a larger medical complex with more than 1000 beds. In 85 (59.0%) cases, the patient developed ileus during index admission, and in 54 (37.5%) cases the woman was readmitted for ileus or SBO. Five (3.5%) patients were diagnosed with ileus or SBO during index admission and were subsequently readmitted for the same diagnosis. In 18 (12.5%) cases, the patient underwent reoperation for bowel obstruction. When made during the index admission, the diagnosis of ileus or SBO occurred within a median time of 2 postoperative days (range, 0–7 days). For patients who were readmitted, the median time to diagnosis was 8 postoperative days (range, 1–358 days). For patients who underwent reoperation, the median time from index surgery to reoperation was 11 days (range, 5–316 days). Fig. 1 demonstrates the outcome of cases. Use of imaging varied among the cases of ileus and SBO. Abdominal X-ray alone was the most common imaging modality—occurring in 54 (37.5%) cases—followed by abdominal X-ray plus computed tomography (CT) in 30 (20.8%) cases, CT alone in 19 (13.2%) cases, and other forms of imaging in 3 (2.1%) cases. Thirty-eight (26.4%) patients did not undergo imaging and were diagnosed based solely on symptomatology and physical examination. Of note, there was no statistically significant difference in time to resolution of symptoms between women diagnosed via imaging of any form and those who underwent no imaging: 4.7 days versus 11.7 days (P = 0.46). Of the 106 women who underwent any form of imaging, 69 (65.1%) received definitive radiologic diagnoses of either ileus (50 [72.5%]) or SBO (19 [27.5%]). The imaging results of the remaining patients did not provide definitive diagnoses, and multiple findings were listed such as “partial SBO, cannot rule out ileus” or “air/fluid levels, may be ileus versus SBO.” Of the women with definitive radiologic diagnoses, 57.9% (n = 11) with SBO diagnoses and 90.0% (n = 45) with ileus diagnoses were managed conservatively, without the need for readmission or reoperation. Fifteen (83.3%) of the 18 patients who underwent reoperation for SBO were diagnosed with partial SBO or SBO on imaging. Bivariate analysis between the rate of reoperation and the imaging results revealed that patients with a diagnosis of SBO on imaging were more likely to undergo reoperation than those diagnosed with ileus on imaging (42.1% vs 10.0%; P = 0.002). Furthermore, the odds of reoperation decreased by a factor of 0.15 (85%) for those with imaging results listed as ileus (95% confidence interval, 0.04–0.56).
Institution 4 n=20
Institution 5 n=15
Institution 6 n=20
Total cases n=144
Dx during index admission n=90
Readmitted for Dx of SBO/ileus n=59
Dx during index admission AND readmitted n=5 Fig. 1. Flowchart of patient outcomes.
Reoperation n=1
Reoperation n=14
Reoperation during readmission n=3
Institution 7 n=23
58
A.M. Allen et al. / International Journal of Gynecology and Obstetrics 121 (2013) 56–59 Table 1 Management of ileus or SBO.a Antiemeticb
Cases (n = 136)c
None Promethazine Metoclopramide Ondansetron Compazine Combination therapy Managementb No intervention Diet reversal NPO NGT Taken to OR
23 (16.9) 61 (44.9) 49 (36.0) 87 (64.0) 6 (4.4) 72 (52.9) 3 (2.2) 23 (16.9) 88 (64.7%) 53 (39.0%) 18 (13.2)
Abbreviations: NGT, nasogastric tube; NPO, nil per os; OR, operating room; SBO, small-bowel obstruction. a Values are given as number (percentage). b Result categories overlap. c Management data unavailable for entire cohort.
The management of ileus and SBO varied (Table 1). Of the 136 women for whom these data were available, 72 (52.9%) received a multi-agent antiemetic regimen upon diagnosis of SBO or ileus, whereas 23 (16.9%) received no antiemetics. Ondansetron was the most commonly administered antiemetic (87 [64.0%] patients). Promethazine (61 [44.9%]) and metoclopramide (49 [36.0%]) were also commonly ordered. Seventy-six (52.8%) patients underwent multimodal management for ileus/SBO, comprising diet regression or continuation of nil per os (NPO) status, placement of a nasogastric tube (NGT), administration of antiemetics, and/or reoperation. Mean time to ileus/SBO resolution was 4 ± 5 days. Resolution was defined by the return of bowel function (tolerating a regular diet without nausea and vomiting). Several management variables were analyzed to identify any correlation between time to resolution and form of management. The cases were divided into 2 groups: resolution of ileus/SBO within 3 days and resolution after 3 days. The variables analyzed included type of antiemetic medication administered and whether a single agent was used versus multiple agents; diet reversal; NGT placement; or a combination of these. Multivariate regression analysis revealed no evidence of a correlation between single versus multiple antiemetics or type of antiemetic and time to resolution of ileus. It also revealed no significant difference in time to resolution between cases in which patients underwent multimodal management and those in which single management (e.g. NGT only or diet reversal only) was used. An additional bivariate analysis was performed to investigate whether there was an association between management modality— with regard to type of antiemetic(s) used, diet administered on postoperative day 1, and NGT placement upon diagnosis—and odds of reoperation. There were no significant differences in rate of reoperation between cases involving the use of single antiemetics and those involving the use of multiple antiemetics (P = 0.18), or between diet statuses (NPO or clear liquids) on postoperative day 1 (P = 0.08). Only 2 patients for whom an NGT was placed underwent reoperation, which prevented adequate statistical analysis. 4. Discussion The present study analyzed practice patterns at 7 academic centers with regard to the diagnosis and management of postoperative ileus/ SBO after benign gynecologic surgery. Diagnostic imaging studies were frequently ordered (73.6%), and abdominal X-ray was the most commonly ordered imaging study, followed by CT. A published survey of gynecologic surgeons revealed similar preferences for imaging modalities for diagnosis of ileus and SBO [9]. Physicians order imaging studies in an attempt to differentiate ileus from bowel obstruction, which may require reoperation. Although abdominal
X-ray is commonly used as a first-line imaging test, previous studies have proven that abdominal CT is more sensitive and specific for differentiating ileus from SBO [6,10,11]. Another study evaluated postoperative imaging in patients with ileus/SBO after benign and gynecologic oncology surgeries; the authors reported that abdominal X-rays had little use in management [12]. Furthermore, there was no correlation in that study between X-ray diagnosis of either ileus or bowel obstruction and the need for reoperation. In the present study, imaging did not always differentiate ileus from SBO; however, patients with a definitive diagnosis of SBO on imaging (whether abdominal X-ray or CT) were more likely to require reoperation compared with those diagnosed with ileus. The present study demonstrated that the majority of centers chose to follow a multimodal approach for the treatment of ileus and SBO. This included the use of multiple antiemetics, diet regression or continuation of NPO status, NGT placement, and/or reoperation. Despite this multimodal approach, none of the management options seemed to decrease the odds of reoperation. The overall rate of reoperation (12.5%) for ileus/SBO was similar to that in previous reports. Heinberg et al. [12] reported a reoperation rate of 8.3% among gynecologic oncology patients diagnosed with ileus/SBO after surgery; most of those patients were treated with multimodal conservative therapies. Several studies indicate that preventive measures such as early postoperative feeding, gum chewing, bowel stimulation, and use of alvimopan and ketorolac may decrease the incidence of postoperative ileus [4]. In fact, early postoperative feeding has been shown to decrease ileus following cesarean delivery under regional anesthesia [13,14] and major gynecologic surgery [15]. Gum chewing has been shown to decrease the incidence of postoperative ileus after colorectal surgery [16] and lead to rapid resumption of intestinal motility and shorter hospital stay after cesarean delivery under general anesthesia [17]. The present analysis did not identify any factors that decreased time to resolution of ileus/SBO. Furthermore, it did not ascertain whether the various management options were used to prevent the onset of ileus/SBO symptoms or to treat symptoms of an underlying pathophysiologic process. The strengths of the study included its multicenter nature, which incorporated different diagnosis and postoperative management styles. It is likely that this reflects more closely the true management strategies of gynecologists throughout the USA. The limitations of the study were related to the retrospective design, including incomplete documentation and variance in the quality of information recorded. In abstracting information from in-patient charts, it is possible that not all management options were captured and included in the analysis. Furthermore, data regarding management options such as gum chewing or ketorolac use were not specifically collected. Data regarding alvimopan use were collected; however, its infrequent usage prevented analysis. In addition, owing to similar clinical presentation and initial management, cases of ileus and SBO were grouped together in the present analysis. It is possible that these diagnoses should not be grouped together because of different pathophysiologic mechanisms of disease. A larger study involving more academic centers would be required to perform an independent analysis of ileus and SBO. In conclusion, most academic centers used abdominal X-ray to diagnose ileus and SBO after benign gynecologic surgery, despite evidence that that CT might be a better discriminatory modality for differentiating the conditions. Most centers used a multimodal approach to the management of ileus and SBO. The present analysis did not identify any management strategy that decreased the time to resolution of ileus or SBO. Acknowledgments The study was supported by the Fellows' Pelvic Research Network (sponsored by the Society of Gynecologic Surgeons). Biostatistical
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support for the project was funded in part by Federal funds (grant No. UL1RR031975) from the National Center for Research Resources and National Institutes of Health, through the Clinical and Translational Science Awards Program. Conflict of interest The authors have no conflicts of interest. References [1] Prasad M, Matthews JB. Deflating postoperative ileus. Gastroenterology 1999;117(2): 489–92. [2] Iyer S, Saunders WB, Stemkowski S. Economic burden of postoperative ileus associated with colectomy in the United States. J Manag Care Pharm 2009;15(6):485–94. [3] Luckey A, Livingston E, Taché Y. Mechanisms and treatment of postoperative ileus. Arch Surg 2003;138(2):206–14. [4] Fanning J, Valea FA. Perioperative bowel management for gynecologic surgery. Am J Obstet Gynecol 2011;205(4):309–14. [5] Livingston EH, Passaro Jr EP. Postoperative ileus. Dig Dis Sci 1990;35(1):121–32. [6] Sajja SB, Schein M. Early postoperative small bowel obstruction. Br J Surg 2004;91(6): 683–91. [7] Whitehead WE, Bradley CS, Brown MB, Brubaker L, Gutman RE, Varner RE, et al. Gastrointestinal complications following abdominal sacrocolpopexy for advanced pelvic organ prolapse. Am J Obstet Gynecol 2007;197(1):78.e1–7.
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