Motility After Abdominal Surgery

Effect of water-soluble contrast in colorectal surgery: A prospective randomized trial

AIM: Postoperative gastrointestinal-tract motility is normally delayed. Early feeding after colorectal surgery has been reported recently, but late feeding is common. Gastrografin not only enhances bowel peristalsis, but also decreases bowel-wall edema. Whether contrast medium allows early oral feeding and reduces the duration of hospitalization requires clarification.

METHODS: Fifty patients underwent elective colorectal surgery in a regional medical center. Patients were prosp-ectively randomized into a Gastrografin group or control group (n = 25 each). Patients in the Gastrografin group began their feeding schedule with 100 mL of 5% dextrose water with 100 mL of Gastrografin on postoperative d 3 and were advanced to a full liquid diet when the contrast reached the colon in 4 h. Patients in the control group began their feeding schedule with 200 mL of 5% dextrose water on postoperative d 3 and were advanced to a full liquid diet after the passage of flatus and stool. Nasogastric tubes were inserted for persistent postoperative vomiting. Fullness, nausea, vomiting, complications, time of anesthesia, time of operation, time of mobilization, time of oral feeding, and duration of hospital stay were recorded and analyzed with Student’s t-test.

RESULTS: In the Gastrografin group, one patient had aspiration pneumonia and one patient had anastomotic leakage resulting in sepsis and eventual death. This mortality was excluded from the subsequent statistical analysis. In the control group, two patients had wound infections. There was no significant difference between the two groups at the time of anesthesia, time of operation, or time of mobilization. There were significant differences between the two groups in the time of oral feeding (3.3±0.3 d in the Gastrografin group vs 4.8±0.4 d in the control group; P = odds ratio--, 95%CI [-0.5 to +0.7 d]) and in the length of hospital stay (7.6±1.1 d in the Gastrografin group vs 10.2±1.3 d in the control group; P = odds ratio--, 95% CI [-1.2 to +1.4 d]).

CONCLUSION: Gastrografin not only allowed early oral feeding but also reduced the duration of hospitalization after elective colorectal surgery.

Effect of Morphine and incision length on bowel function after colectomy

PURPOSE

Return of bowel function remains the rate-limiting factor in shortening postoperative hospitalization of patients with colectomies. Narcotics are most commonly used in the management of postoperative pain, even though they are known to affect gut motility. Narcotic use has been felt to be proportional to the length of the abdominal incision. The aim of this study was to determine whether return of bowel function after colectomy is directly related to narcotic use and to evaluate the effect of incision length on postoperative ileus.

METHODS

A prospective evaluation of 40 patients who underwent uncomplicated, predominantly left colon and rectal resections was performed. Morphine administered by patient controlled analgesia was the sole postoperative analgesic. The amount of morphine used before the first audible bowel sounds, first passage of flatus and bowel movement, and incision length were recorded. Spearman correlation coefficients were calculated between all variables.

RESULTS

The strongest correlation was between time to return of bowel sounds and amount of morphine administered (r = 0.74; P = 0.001). There were also significant correlations between morphine use and time to report of first flatus (r = 0.47; P = 0.003) and time to bowel movement (r = 0.48; P = 0.002). There was no relationship between incision length and morphine use or incision length and return of bowel function in the total group.

CONCLUSIONS

Return of bowel sounds, reflecting small-intestine motility after colectomy, correlated strongly with the amount of morphine used. Similarly, total morphine use adversely affects colonic motility. Because no relationship with incision length was found, efforts to optimize the care of patients with colectomies should be directed less toward minimizing abdominal incisions and more toward diminishing use of postoperative narcotics.

Must early postoperative oral intake be limited to laparoscopy?

PURPOSE

This prospective, randomized study was designed to evaluate whether or not early postoperative feeding (claimed as a unique benefit of laparoscopic surgery) is possible after laparotomy and colorectal resection.

METHODS

The trial was performed between July 1, 1992 and October 31, 1992 and included all 64 consecutive patients who underwent laparotomy with either a colonic or an ileal resection. In all cases the nasogastric tube was removed immediately after the operation. Group 1 consisted of 32 patients (age range, 15-81 years; mean, 52 years) who received a regular diet on the first postoperative morning. Group 2 consisted of 32 patients (age range, 15-87 years; mean, 52 years) who were fed in a traditional manner. Regular food was permitted after resolution of ileus as defined by resumption of bowel movements in the absence of abdominal distention, nausea, or vomiting.

RESULTS

The rate of nasogastric tube reinsertion for distention with persistent vomiting was 18.7 percent (six patients) in Group 1 and 12.5 percent (four patients) in Group 2. Although vomiting was experienced more frequently by patients in Group 1 (44 percent vs. 25 percent, respectively), there was no difference between the two groups with regard to the duration of postoperative ileus (3.6 vs. 3.4 days, respectively). In the 26 patients from Group 1 who did not require nasogastric tube reinsertion, there was a trend toward shorter hospitalization (6.7 vs. 8.0 days, respectively).

CONCLUSION

Early oral intake is possible after laparotomy and colorectal resection. Thus, the laparoscopic surgeon's claim of early tolerated oral intake may not be unique to laparoscopy.

Pathophysiology of small intestinal motility

Only in the last few years have we begun to understand the effects of surgical procedures on contractile activity of the small intestine. Although most patients readily adapt to the procedures that are performed, operations such as small intestinal transplantation make it imperative that we pursue a more thorough understanding of the effects of surgery on the motility of the small intestine.

Cisapride in the prophylaxis of equine post operative ileus

Cisapride and domperidone were both effective in restoring electrical and mechanical activity, coordination between gastric and small intestinal activity cycles and the stomach to anus transit time in three ponies in which post operative ileus was induced experimentally. Cisapride (0.1 mg/kg bodyweight intramuscularly) for three to eight doses prevented idiopathic post operative ileus in 22 clinical cases requiring colic surgery. The only side effects after cisapride were increased bowel sounds and slight, transient sounds of discomfort. No adverse side effects were seen in 16 cases following anastomosis or enterotomy. Cisapride appears safe and effective in the prophylaxis of equine post operative ileus.

Effects of epidural bupivacaine and epidural morphine on bowel function and pain after hysterectomy

A comparison was made of the effects of continuous epidural analgesia with bupivacaine and intermittent epidural morphine on bowel function after abdominal hysterectomy. The duration of postoperative ileus was assessed as the time from the end of operation to the first postoperative passage of flatus and feces. Twenty-two patients were randomly allocated to two equal groups. An "epidural morphine" group received general anesthesia and epidural morphine for postoperative pain relief, and an "epidural bupivacaine" group was given combined general anesthesia and epidural anesthesia with 0.5% bupivacaine intraoperatively and epidural analgesia with 0.25% bupivacaine postoperatively. Epidural morphine or bupivacaine was given for 42 h postoperatively. Pain intensity (visual analog scale) was low in both groups, but lower (P less than 0.05) in the epidural bupivacaine group. The time to first passage of flatus was 22 +/- 16 h in the epidural bupivacaine group and 56 +/- 22 h in the epidural morphine group (P less than 0.001). The time to first postoperative passage of feces was shorter (P less than 0.05) in the former than in the latter 57 +/- 44 h vs 92 +/- 22 h). The patients of the epidural bupivacaine group started intake of oral fluids earlier (P less than 0.01) and to a greater extent (P less than 0.05) than those in the epidural morphine group. It is concluded that the duration of postoperative ileus after hysterectomy is shorter when epidural bupivacaine is given for postoperative pain relief than when this is achieved by epidural morphine.

Epidural morphine delays gastric emptying and small intestinal transit in volunteers

The influence of a painful stimulus and lumbar epidural morphine on gastric emptying, the orocecal transit time and small intestinal transit were studied in nine healthy volunteers. Acetaminophen absorption was used as a measure of the rate of gastric emptying. Orocecal transit time was determined by measuring the end-expiratory hydrogen concentration. Small intestinal transit was calculated from measurements of the orocecal transit time and gastric emptying. Cold pain stress with intermittent immersion of the feet in ice-cold water was used as a painful stimulus. Each volunteer was investigated on 3 different days: once after receiving 4 mg of epidural morphine and during cold pain; once during cold pain; and once under control conditions without pain and epidural morphine. Immersion of the feet in ice-cold water was always very painful, but was more tolerable during epidural morphine analgesia. The increase in blood pressure which accompanied the cold pain was the same whether this pain was induced without or during epidural morphine analgesia. Gastric emptying, orocecal transit time and small intestinal transit were delayed during epidural morphine analgesia compared with the findings under the control and plain cold pain conditions. Cold pain stress alone did not influence gastric emptying, orocecal transit time or intestinal transit. To conclude, epidural morphine in itself delayed gastric emptying, orocecal transit and transit through the small intestine in healthy volunteers.