M

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M M

• NOV 21st 2006
• COMPLICATION
• POST-OP ILEUS
• Jabbar Saliba, MD

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H P

• Name JG. B. 60 yo B male
• Dx Left Colonic Polyp.
• S/P Screening Colo 08-29-2006 polypoid colonic
  mass _at_ 40cm from the anus.
• Path tubular adenoma with high grade dysplasia
• Proc/Date Open Left Hemicolectomy 11-06-20

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Medical History

• PMH
• HTN
• Rt CVA
• Colonic polyp
• PSH
• GSW to Lt Chest and Lt Leg.
• Tonsilectomy

• Allergies
• NKDA
• Tobacco Current smoker
• Alcohol NO use

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Procedure NOV 6th 2006

• Partial colectomy of the splenic flexure 55-60cm
  from the rectum through a midline incision with
  end to end anastomosis. JP drain placed around
  the pancreatic area. EBL 650ml
• Path Flat sessile polypoid 2cmx1.7cmx0.5cm mass
  from the sigmoid colon.
• Invasive well differentiated adenocarcinoma.
• Clear Margins
• PT1NoMx

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POST OPERATIVE COURSE

• POD-2 11/08
• Tmax 38.6ºC, WBC 20 CX-Ray new LLL consolidation
  Bld Urine and Sp Cx neg
• Abd. Exam distended JP 100, NGT 170.
• K 3.5
• Antibiotics changed to MOXIFLOXACINE.
• PCA

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POD-3 11/09

• SBP 180-190 mm Hg
• Started on NTG patch (1in).
• Started on Prazosin 5mg BID.
• Was on metoprolol 10 IV Q4h.
• Given lasix 10.
• K 3.0 given 50 Meq.

• Abd still distended no pain no flatus NGT 300, JP
  125 wound no cellulitis
• A/P CT WO contrast post-op changes mild ileus
• WBC 19.6.

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POD-7 11/13

• PCA D/Ced
• SBP in 190-210 Transferred to the ICU
• Labetolol and Nifedipine added for 24 h
• Abd. Distended, vomiting, NGT 1700, JP 30 WBC
  15.9
• Rt SCL placed
• K 3.1 given 40 Meq, Mg 2.4

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POD-8 11/14

• SBP 160-190 mm Hg
• Distended Abd. WBC 14
• Repeat CT mod. dilat. Of proximal and mid small
  bowel (focal narrowing of the descending colon).
• TPN ( Goal 1.9 Kcal/Kg, Prot 1.1 gr/Kg ABW)
• K 4.0

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POD-9 11/15

• Transfer to the floor

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POD 10-12

• SBP 150-170s mmHg
• Abd distended NGT 1325, JP 60 (JP amylase 162 Cx
  Neg) WBC 14.8-16.7-18.5. TLC change over a guide
  wire Tip Cx Neg, foley D/Ced. Bil LE Dupplex Neg

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POD 13(11/19)-

• SBP 140-170s mm Hg(on NTG patch, Metoprolol,
  Labetolol, Enalapril).
• Abd Softer, Flatus, started on clear liquids
  30cc/h WBC 15-14.9
• K 3.9
• TPN

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ILEUS

• DEF Alteration in the motility of the GI tract
  leading to functional obstruction.

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Historical

• Classified as paralytic (non mechanical)
  intestinal distension in 1884 by Frederis
  Treves.
• Swallowed air as the cause of distension was
  proved by Wangersteen.

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Contributing factors

• Neurogenic
• SCI
• Retroperitoneal process, hematoma, tumor
• Ureteral colic
• Metabolic
• Hypokalemia
• Uremia
• Ca2 , Mg2 imbalance
• Hypothyroidism
• Diabetic coma and ketoacidosis

• Pharmacologic
• Anticholinergics
• Opiates
• Autonomic blockers
• Antihistamines
• Psychotropics
• Haloperidol
• Tricyclic antidepressants
• Clonidine
• Vincristine
• Infectious
• Systemic sepsis
• Pneumonia
• Peritonitis
• Bacterial overgrowth
• UTI

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Prevention Treatment

• NPO
• NGT Suctioning decrease the distension but does
  not reduce time to flatus or to effective oral
  intake. Ann Surg. 1995 May 221(5) 469478.
• Mobilization Walking Does not shorten ileus
  but has benefits in reducing morbidity. Ann Surg.
  1990 December 212(6) 671677

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Prevention Treatment

• Laxatives No controlled studies proven to be
  beneficial.
• Prokinetic agents
• Metoclopramide no significant impact on duration
  of ileus (Dis Colon Rectum. 1991 Jun
  34(6)437-41.)
• Cisapride not FDA approved - cases of fatal
  arrhythmias.
• NSAIDs (i.e. Ketorlac)
• May decrease the need to use opioids by 20-30
• May decrease the release of local inflammatory
  mediators.

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GOLDEN RULE PREVENTION

• Minimize trauma to tissues
• Minimal use of narcotics
• NSAIDS when no contraindication
• Early correction of metabolic abnormalities
• Early recognition of septic complications.

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Thank you