The Ileus and Oddities After Colorectal Surgery

Tonna McCutcheon , MSN, APRN-BC, CGRN

3.8 ANCC Contact Hours The Ileus and Oddities After Colorectal Surgery

ABSTRACT Colorectal surgery is a necessity for many disease processes such as diverticulitis, ulcerative colitis, Crohn disease, and colorectal cancers as well as for the many complications of such conditions. The incidence of overall complications related to colorectal surgery has been reported to be between 10% and 30%. Prevention is the necessary key to avoid complications and this may be improved by adequate selection of appropriate procedures for the patient, good surgical technique, and good postoperative care. Nevertheless, complications do occur intraoperatively or postoperatively and must be managed in a timely manner to improve overall patient outcomes. Such complications include paralytic ileus, anastomotic leak, abdominal sepsis, acute mesenteric ischemia, anastomotic bleeding and hemorrhage, wound infection, anastomotic dehiscence and ﬁ stula formation, small bowel obstruction, and genitourinary complications.

olorectal surgery is a necessity for many dis- Postoperative Ileus ease processes as well as for the many com- A postoperative ileus is defined as a temporary paraly- plications that accompany such conditions. sis of a portion of the intestines after abdominal sur- The incidence of overall complications relat- gery. This paralysis is a normal physiological response ed C to colorectal surgery has been reported to be between most often involving the sigmoid colon and resolves in 10% and 30% (Ruis-Tovar, Morales-Castinerias, & 2–3 days postoperatively. Fifty percent of major Lobo-Martinez, 2010). The American Society of abdominal surgeries result in a postoperative ileus Colorectal Surgeons (ASCRS) reported that over an ( Senagore , 2007). If paralysis persists, it is known as a 8-year period (1988–1994), the mortality rate for paralytic or adynamic ileus and is then considered a patients undergoing colorectal surgery was 1.4% if the complication of surgery. A paralytic ileus occurs after procedure was performed by a board-certified colorec- intraperitoneal, retroperitoneal, or extra-abdominal tal surgeon as compared with a 7.3% mortality rate surgery but colonic surgery has the highest rate of when performed by other surgeons (ASCRS, 1996). paralytic ileus with laparoscopic colon surgery having Prevention of complications may be improved by ade- lower occurrence than open colonic procedures ( Cagir, quate selection of appropriate procedures for the 2013). patient, good surgical technique, and good postoperative care. Nevertheless, complications do occur intraoperatively and/or postoperatively and must be managed Causes in a timely manner to improve overall patient outcomes. In general, an ileus causes backup of gas and fluids in the colon and may occur because of activation of Received January 20, 2012; accepted April 26, 2012. inhibitory spinal reflex arcs. Long reflexes involving the spinal cord are linked and spinal anesthesia, About the author: Tonna McCutcheon, MSN, APRN-BC, CGRN, is Colorectal Acute Care Nurse Practitioner, Vanderbilt Medical Center, abdominal sympathectomy, or cutting of nerves may Nashville, Tennessee. lead to a temporary paralysis of the bowel. Another The author declares no conflict of interest. thought is a surgical stress response that causes inflam- Correspondence to: Tonna McCutcheon, MSN, APRN-BC, CGRN, matory and endocrine mediators to be released, thus Vanderbilt Medical Center, 1121 21st Ave. S, S-5410 MCN, Nashville, leading to bowel paralysis. Other reported causes of an TN 37232 ( [email protected]). ileus include medications (warfarin [Coumadin], opi- DOI: 10.1097/SGA.0b013e3182a71fdf oids, antacids, amitriptyline, and chlorpromazine),

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hypokalemia, hyponatremia, hypomagnesemia, ane- and includes removal of obstruction, repair of hernias, mia, intra-abdominal inflammation or peritonitis, sur- lysis of adhesions, and resection of any ischemic bowel gical manipulation of the intestine, effects of anesthe- ( Ansari , 2012). sia, and retroperitoneal hematomas ( Oncel & Remzi, Pseudo-obstruction is the acute marked distention 2003). Resolution of an ileus is from the proximal or of the large bowel in the absence of definable mechan- right colon to the distal or left colon. Normally the ical pathology (National Digestive Diseases Information small bowel regains function within hours whereas it Clearinghouse, 2013) and is most often limited to and may take 3–5 days for the colon to regain function. occurs in the right colon. Causes and risk factors for development of a pseudo-obstruction include elderly Signs and Symptoms bedridden patients, trauma patients, medications, sep- Signs and symptoms of a paralytic ileus include mild sis, electrolyte imbalance, and aerophagia (swallowing abdominal pain and bloating, nausea, vomiting, poor of too much air). Signs and symptoms include abdom- appetite, distended and tympanic abdomen, constipa- inal distention without pain or tenderness, nausea, tion, obstipation, absent or hypoactive bowel sounds, vomiting, constipation, obstipation, anorexia, hypoac- and passing flatus or stool. Bowel sounds should be tive or hyperactive bowel sounds, local tenderness, auscultated to help differentiate paralytic ileus from a borborygmi, and abdominal distention. mechanical ileus. Continued absence of bowel sounds Diagnosis is made from plain abdominal x-ray suggests paralytic ileus whereas hyperactive bowel films, which will indicate isolated proximal large sounds may indicate a mechanical ileus ( Ruis-Tovar bowel dilatation and an elevated diaphragm. A cecal et al. , 2010). diameter of greater than 12 cm indicates a high risk for cecal perforation, which has a subsequent mortality Differential Diagnoses rate of 50% if ischemic bowel develops, leading to Differential diagnoses for a paralytic ileus include perforation. Contrast imaging is also helpful in distin- mechanical bowel obstruction and pseudo-obstruction. guishing a pseudo-obstruction from a mechanical Mechanical bowel obstruction is defined as a complete obstruction as mentioned earlier. Treatment for a or partial obstruction of the bowel due to a physical pseudo-obstruction includes hydration, nasogastric blockage. It is more common in the small intestine (NG) tube placement, possible rectal tube placement, than in the colon and may be caused by neoplasm, correction of electrolyte imbalance, discontinuation of adhesions from previous surgeries, volvulus, hernia, medications that may promote immotility, or decom- Crohn disease, foreign bodies, and intussusceptions. pression by way of a colonoscopy. Another treatment Mechanical obstruction of the large intestine may be is the administration of intravenous (IV) neostigmine, caused by stricture, impacted feces, volvulus, diverticu- which will resolve a pseudo-obstruction within 10–30 litis, or colon cancer ( Mayo Clinic , 2012). minutes; however, it must be given under cardiac Signs and symptoms include severe abdominal monitoring because there is a high risk of bradycardia. cramping, constipation, obstipation, nausea, vomiting, Surgery is indicated if peritonitis, ischemia, or perfora- anorexia, borborygmi (rumbling sounds caused by gas tion is present and an exploratory laparotomy with moving throughout the intestine), high pitched tinkling bowel resection and placement of an ostomy is the sounds heard upon auscultation, abdominal disten- procedure of choice. tion, and localized tenderness may be present on physical examination. If the patient is thin, peristaltic Laboratory Data waves may be observed as well. If a complete obstruc- Abnormal laboratory values that are seen in a patient tion is present, the patient may present with constipa- experiencing a paralytic ileus include hypokalemia, tion, obstipation, vomiting (depending on the ileocecal hyponatremia, and hypomagnesemia. Leukocytosis valves ability to prevent reflux), and peritoneal signs if may be present; however, it is nonspecific and may be strangulated obstruction or perforation has developed. due to an infectious causes or hemoconcentration. Diagnosis of a mechanical obstruction is most often Serum amylase may increase and hypoproteinemia can made with the use of contrast imaging such as a com- also be present ( Ruis-Tovar et al. , 2010). puted tomographic (CT) scan that will suggest enlarged bow shaped loops of small bowel in a step like pattern, Radiographic Data a colonic gas pattern distal to the lesion, presence of Diagnosis of a paralytic ileus is made from plain air-fluid levels, and a mildly elevated diaphragm abdominal films or a CT scan. Plain films will indicate ( Cagir, 2013). Treatment for a partial mechanical dilatation of the small and large bowel as well as ele- obstruction includes bowel rest and a low-residue diet. vation of the diaphragm. Serial abdominal films are If the obstruction does not resolve or complete obstruc- done daily to evaluate for worsening of the ileus. Most tion is present, surgical intervention may be indicated often a paralytic ileus will resolve over time with

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supportive treatment that includes hydration and inhibit adverse gastrointestinal effects of an opioid. bowel rest with NG tube placement. If a continued or These medications do not cross the blood-brain barrier protracted ileus develops, a mechanical ileus must be and thus do not hinder the analgesic effect of the opi- ruled out and evaluation of electrolyte imbalance is oid ( Cagir, 2013). indicated as well. Other agents such as bisacodyl have been of some benefit with improving a paralytic ileus, and periopera- Treatment tive administration of a low dose of celecoxib has also Treatment of a paralytic ileus is the same as mentioned been shown to reduce development of an ileus. previously for a pseudo-obstruction and involves bowel Erythromycin is not helpful with resolution of an ileus rest and possible NG tube placement. Nasogastric tube despite its use for gastroparesis; Reglan has been placement is beneficial only if the patient experiences shown to worsen an ileus ( Cagir, 2013). vomiting or abdominal distention. The tube should be If there is no resolution in a paralytic ileus within removed when there is 100 ml or less output after 48–72 hours, the patient reports an increase or wors- clamping the tube for 4 hours (Oncel & Remzi, 2003). ening of symptoms, or serial abdominal films suggest Medications that slow down motility are discontin- worsening of bowel dilation, an exploratory laparot- ued and narcotic pain medications can be switched to omy is done. Early surgical intervention allows for nonsteroidal anti-inflammatory drugs, which will help better outcome so surgery most often is done prior to with local inflammation and, in turn, may help resolve 7 days of obstructive symptoms. After 7–10 days, the the ileus. Side effects of nonsteroidal anti-inflamma- intestine has an increased risk of being edematous or tory drugs, however, are worrisome and include plate- necrotic. Recurrent paralytic ileus is uncommon; let abnormalities and gastric ulceration. Ruis-Tovar et however, cardiac, renal, urinary, vascular, and pulmo- al. (2010) also report that Gastrografin enemas may be nary complications are frequent (Ruis-Tovar et al., therapeutic. 2010). Delay of reintroduction of food is advisable until the ileus totally resolves; however, this does not pre- Case Study clude enteral feeding, which can be done as a postpy- A 70-year-old man underwent an elective laparoscopic loric feeding directly into the small bowel. The for- right hemicolectomy for a cecal polyp without diffi- mula is given at a quarter to half strength, at a slow culty or complication. Postoperatively, his pain was rate, and advanced slowly. Oncel and Remzi (2003) well controlled; however, his bowel function was slow note that allowing oral intake earlier in the postop- to return. On postoperative Day 4, he developed nau- erative period does not affect overall bowel recovery; sea and vomiting and a CT scan was obtained, which therefore, starting a postoperative patient on clear revealed contrast throughout the bowel with evidence liquids on postoperative Day 1 is acceptable rather of a partial small bowel obstruction. A NG tube was than awaiting return of bowel function to begin placed and the patient reported onset of flatus and feedings. small bowel movements. On physical examination, Gum chewing is also an acceptable method to help however, the patient remained distended. resolve an ileus because this promotes gastrointestinal A peripherally inserted central catheter was placed motility and has been shown to reduce the amount of and total parenteral nutrition (TPN) was started. Serial time for return of bowel function postoperatively, abdominal films showed no change or resolution of the reducing the overall length of a hospital stay after colo- partial obstruction. On postoperative Day 12, a second rectal surgery (Hocevar, Robinson, & Gray, 2010). CT scan was obtained revealing decompressed bowel Ambulation is thought to help resolve a paralytic ileus, after a transition point in the ileocolic region. It was but there is currently no literature to support this the- decided to take the patient back to the operating room ory. Ambulation seems only to help prevent pneumo- (OR) for an exploratory laparotomy. nia, deep vein thrombosis, and atelectasis. During surgery, a thin adhesion was found near the Studies have indicated epidural blockade with local anastomosis and was removed. The patient recovered anesthetics, especially bupivacaine alone or in combi- well from the exploratory laparotomy; however, his nation with an opioid, can improve postoperative bowel function continued to be slow to return to base- ileus. Other studies have also indicated that continuous line. For this reason, he was kept on TPN to maintain IV administration of lidocaine intraoperatively and his nutritional status. On postoperative Day 21, the postoperatively may decrease the length of a postop- patient was found stable for discharge after he reported erative ileus by blocking the inhibitory reflexes and flatus, a bowel movement, and his abdominal disten- efferent sympathetic responses thus preventing paraly- sion was resolving without an NG tube in place. The sis of the bowel. Opioid antagonists such as Entereg patient was discharged on TPN to progress his diet and Relistor inhibit peripheral μ -opioid receptors that slowly, as tolerated.

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Anastomotic Leak there have been no reported differences in rates of An anastomotic leak is a major complication of colo- anastomotic leaks in patients undergoing an open rectal surgery and may result in peritonitis, abscess colorectal resection for cancer versus a laparoscopic formation, increased risk of local cancer recurrence, procedure. increased length of hospital stay, decreased functional The use of a stoma to prevent anastomotic leaks is outcomes, increased risk for a permanent ostomy, and controversial. Boushey and Williams (2013) indicated death ( Whiteford , 2013). In 2011, an estimated risk of studies that, in fact, found a decrease in the number of an anastomotic leak after colorectal surgery was a leaks in patients with a stoma as compared with reported 3%–6% when performed by experienced sur- patients without a stoma. However, another study was geons. Overall, a low pelvic anastomosis (coloanal also referenced, which indicated that the rate of anas- anastomosis) had a risk of 10%–20% for an anasto- tomotic leaks was similar in patients with and without motic leak as compared with a high anastomosis (small a stoma. bowel and ileocolic anastomosis), which had a 1%–3% leak rate ( Boushey & Williams , 2013; Dietz , 2011). Signs and Symptoms Anastomotic leaks may become symptomatic as early Risk Factors as 5–7 days postoperatively. Fifty percent will present Risk factors for an anastomotic leak include patients after the patient is discharged home and another 12% with comorbidities such as malnutrition, diabetes mel- will occur after 1 month postsurgery. Anastomotic litus, anemia, chronic obstructive pulmonary disease, leaks present as an asymptomatic leak, a subtle leak, or or patients treated with corticosteroids. Patients with a a dramatic early leak as indicted by Whiteford (2013). history of neoadjuvant therapy or patients undergoing Asymptomatic leaks in which the leak was found ileal pouch anal anastomosis with the use of greater incidentally on CT scan weeks to months postopera- than 40 mg daily of prednisone and taking biologic tively are often walled off sinuses and most often no agents such as infliximab are also at an increased risk treatment is necessary. for an anastomotic leak ( Dietz , 2011). Boushey and Subtle leaks usually occur 5–14 days postopera- Williams (2013) reported a retrospective study from tively and present with what seems to be normal post- 1980 to 1995 that looked at low colorectal anastomo- operative symptoms such as low-grade fevers, ileus, sis less than 5 cm from the anal verge. The study indi- and mild leukocytosis whereas dramatic early leaks cated that obese patients had an increased risk (33%) will present with acute abdominal pain, prolonged of developing an extraperitoneal anastomotic leak as ileus, abdominal distention, fevers, tachycardia, oligu- compared with nonobese patients (15%). They also ria, purulent drainage, diffuse peritonitis, and possible found that men undergoing a low pelvic resection for shock. These symptoms indicate an uncontained leak rectal cancer with an anastomosis less than 5 cm from ( Whiteford , 2013). the anal verge were more likely to experience an extraperitoneal anastomotic leak as compared with female Radiographic Data patients. The thought was that the narrow pelvis of the Fluid- or gas-containing collections will be seen on male lends to more difficult dissection ( Boushey & radiography (x-ray); however, small contained leaks Williams, 2013). that present later in the postoperative period are often Neither gender nor obesity factors into an increased hard to distinguish from a postoperative abscess radio- risk of development of an anastomotic leak for intra- graphically. If the CT scan indicates an abscess less peritoneal anastomosis creation. Other risk factors than 3 cm and contained, the patient may be managed include the patient's age, abnormal serum albumin, with antibiotics ( Whiteford , 2013). In general, once an elevated liver function studies, abnormal prothrombin anastomotic leak has been identified on a CT scan or times, the need for transfusions, presence of inflamma- Gastrografin enema, IV hydration and broad-spectrum tion of the bowel, emergent surgery versus elective antibiotics should be initiated. Further treatment surgery, prolonged operative time, inadequate blood involving antibiotics with observation versus percuta- supply, tension on the area of anastomosis, and a neous drain placement versus exploratory laparotomy hand-sewn ileocolic anastomosis as compared with a is determined by the clinical stability of the patient stapled ileocolic anastomosis. There was no noted ( Whiteford , 2013). increase in leak found with a hand-sewn colorectal anastomosis ( Boushey & Williams, 2013). Treatment Neoadjuvant radiation therapy has been reported Patients who present with localized peritonitis, low- to have a positive effect, inconclusive effect, and no grade sepsis, and a CT scan indicating a free intraperi- effect on the development of anastomotic leaks. The toneal leak should undergo an exploratory laparotomy use of drains is also inconclusive as a risk factor, and with surgical management of the leak. Intraoperatively,

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gross enteric spillage and anatomic breakdown of the The patient was discharged home with continued anastomosis will be seen. If the anastomotic defect treatment with IV antibiotics. One week later, the (ischemia and/ or necrosis) is greater than 1 cm or patient informed the colorectal clinic that his drain greater than one third the circumference of the anasto- “fell out.” A repeat CT scan was done, which indi- mosis, the options are resection of the anastomosis cated persistence of the multiple intra-abdominal fluid with the creation of an end stoma with possible collections and a second CT-guided PERC drain was mucous fistula or resection of the anastomosis with inserted. The patient remained on IV antibiotics for proximal diversion with a loop ileostomy ( Boushey & 4 weeks per recommendation of the infectious disease Williams, 2013). If the CT scan indicates a large consultant. A follow-up CT scan indicated resolution abscess greater than 3 cm, multiple fluid collections, or of the intra-abdominal abscesses and the drain was multiloculated fluid collections and the patient is clini- removed. cally stable, the patient should undergo a percutaneous (PERC) drain placement. Leaks managed with Abdominal Sepsis CT-guided PERC drain insertion may heal spontane- Abdominal sepsis is caused by the release of bacteria ously or may develop an enterocutaneous fistula with from the intestinal lumen during a bowel resection accompanying anastomotic stricture. Surgery for this with an increase in risk in emergent cases with no issue is usually delayed approximately 6 months to bowel preparation. Abdominal sepsis can be either allow for resolution of inflammation ( Dietz , 2011). localized or generalized peritonitis as well as enterocol- itis, septicemia, abscess, or phlegmon. Case Study A 56-year-old man underwent a laparoscopic total Symptoms abdominal colectomy with ileostomy for ulcerative The most common symptom is pain. If this pain is colitis. His postoperative course was unremarkable located at the location of the anastomosis, it becomes and he was discharged home on postoperative Day 4. concerning for abscess formation. In general, symptoms Approximately 2 weeks later, the patient was readmit- of abdominal sepsis include fever, tachycardia, and ted to the hospital for tachycardia and leukocytosis tachyphemia. Sepsis related to gram-negative bacteria with concern for a possible bowel perforation. can present with hypotension, hypothermia, and brady- A CT scan was obtained, which indicated a moder- cardia. Tachyphemia may suggest a pulmonary origin ate amount of free intraperitoneal air as well as a small such as a pulmonary embolis (Ruis-Tovar et al., 2010). amount of free intraperitoneal fluid within the left para-colic gutter with uncertainty as to whether this Laboratory and Radiographic Data represented postoperative air versus an anastomotic Laboratory data will indicate leukocytosis with neu- leak. The patient was treated with antibiotics and trophilia and at times an increase in C-reactive protein symptoms were resolved. and erythrocyte sedimentation rate. Wound cultures Two weeks later, the patient presented to the colo- with sensitivity should be done. Chest radiography is rectal clinic with the complaint of lower abdominal usually done to rule out pneumonia, atelectasis, and pain and drainage from the ileostomy. A repeat CT pleural effusion. A urinalysis with culture and sensitiv- scan indicated multiple intra-abdominal fluid collec- ity is also done to rule out a urinary tract infection, tions and a 2-week course of oral antibiotics was given which may only present with disorientation, agitation, because the patient refused PERC drainage at that or other behavioral changes in the elderly. Abdominal time. The patient then developed malaise, nausea, left films may also be done to evaluate for pneumoperito- lower quadrant pain, and purulent drainage from the neum, which is not uncommon (in small amounts) for ileostomy, and had poor oral intake. A complete blood up to 2 weeks postoperatively. Dilation of the bowels cell count indicated leukocytosis, and a repeat CT scan seen on plain films may suggest paralytic ileus second- indicated an interval increase in the size of multiple ary to mechanical injury or peritonitis. An abdominal intra-abdominal and pelvic abscesses as well as a slight CT scan is the best diagnostic tool to determine intra- increase in the parastomal abscess as compared with abdominal fluid collections and for evaluation of the prior studies. anastomosis and presence of intraluminal air. The patient was admitted, placed on IV ciprofloxacin and metronidazole, and underwent a CT-guided PERC Treatment drain insertion. Cultures were taken and indicated If a fluid collection is observed, a PERC drain can be growth of methicillin-resistant Staphylococcus aureus placed under CT guidance. Management of mild or and alpha streptococcus. An infectious disease consulta- localized infection includes supportive care with fluids, tion was obtained, and antibiotics were switched to IV correction of electrolyte imbalance, and initiation of ertapenem, vancomycin, and Diflucan (fluconazole). antibiotics. Cases with intra-abdominal contamination

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or with hemodynamic instability require surgical inter- tachyphemia, hypotension, altered level of conscious- vention with drainage and abdominal washout, possi- ness, and fever). ble colon resection of the infected area, lysis of adhesions, and creation of an ostomy because an anastomo- Radiographic Data sis is impossible in the setting of infection. Most of Unless the patient is medically unstable, plain films these patients do not undergo primary closure of the should be done to evaluate for free air, ileus, obstruc- surgical wound initially and may return to surgery in tion, volvulus, or intussusception. A CT scan should 48 hours for primary closure. Often, retention sutures be done with the use of oral and IV contrast if the are placed because the risk of evisceration is high cause of symptoms is not apparent on the plain ( Ruis-Tovar et al., 2010). films. Angiography may also be done to pinpoint the site of an arterial occlusion, but is less sensitive for Acute Mesenteric Ischemia venous occlusion and cannot demonstrate nonocclu- Acute mesenteric ischemia is a condition that causes an sive disease secondary to low cardiac output or inadequate blood circulation to the mesentery leading hypovolemia. to intestinal ischemia and eventual gangrene of the bowel. Dang and Giebel (2013) report that the inci- Treatment dence of acute mesenteric ischemia is approximately Treatment is resection of the necrotic bowel; however, 0.1% of all hospital admissions. This condition is seen before surgery, the patient's cardiovascular status more often in patients older than 50 years; however, should be improved as much as possible with IV fluid there are no sex or racial predilections. Prognosis for resuscitation and oxygenation. Prophylactic antibiotics acute mesenteric ischemia is poor with a range of are also administered. Most often the patient will 59%–93% mortality rate. If a bowel wall infarction return to surgery in 24–48 hours for a second look to occurs, the mortality rate increases to 90% (Dang & reevaluate bowel circulation ( Dang & Giebel , 2013). Giebel, 2013). Early recognition and treatment can reduce morbidity/mortality rates, especially if treated Acute Mesenteric Ischemia Case less than 12 hours from the onset of symptoms. Study However, Dang and Giebel (2013) reported that A 76-year-old woman was admitted to the hospital patients might still suffer complications related to the and underwent an elective exploratory laparotomy reduced amount of intestine mucosal surface needed with sigmoid colectomy for recurrent diverticulitis. for absorption. Her postoperative course included a postoperative ileus. However, on postoperative Day 6, she developed Causes acute abdominal pain for which a CT scan of the abdo- Acute mesenteric ischemia may be caused by either a men was performed. Imaging revealed pneumatosis venous or arterial obstruction and, in general, causes and portal venous gas consistent with ischemic bowel may include cardiac emboli, atherosclerotic vascular or acute bowel injury. She was taken immediately to disease, aortic aneurysm or dissection, congestive heart the OR for exploratory laparotomy. Findings at that failure, decreased cardiac output from suffering a time included widespread dusky bowel with an area in myocardial infarction, sepsis, severe renal or liver dis- the midjejunum consistent with full-thickness necrosis. ease, cardiac or abdominal surgery, vasopressive drugs, This area was resected, the bowel was left in disconti- cocaine, hypercoagulability, tumor causing venous nuity, and she was transported to the surgical intensive compression, intra-abdominal infection (diverticulitis, care unit (SICU) for further resuscitation. abscess, appendicitis), venous congestion from cirrho- At this point, the patient required multiple vaso- sis, venous trauma from accidents, increased intra- pressors and dobutamine for maintenance of her blood abdominal pressure from a pneumoperitoneum from pressure. A Swann Ganz catheter was placed on admis- laparoscopic surgery, pancreatitis, or decompression sion to the SICU and her hemodynamic parameters sickness ( Dang & Giebel , 2013). were consistent with severe cardiogenic shock. She underwent resuscitation with fluid and blood prod- Signs and Symptoms ucts, and a dobutamine drip was started for inotropy. The most common symptom of acute mesenteric The patient was noted to have a large increase in her ischemia is pain, which is disproportionate to the troponins and cardiology was consulted. physical examination and may be severe to moderate, Echocardiography revealed severe anterior wall constant, diffuse, nonlocalized, and at times described hypokinesis concerning for myocardial infarction. A as “colicky.” Other symptoms are nausea, vomiting, cardiac catheterization was performed with no evi- diarrhea, obstipation, abdominal distention, gastroin- dence of coronary lesion. The diagnosis was stress- testinal bleeding, and signs of sepsis (tachycardia, induced cardiomyopathy. She returned to the SICU in

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a critical condition, requiring vasopressor support and Wound Infection dobutamine. A postoperative superficial wound infection is one of The patient returned to the OR at which point wide- the most common complications of colorectal surgery. spread necrosis of her entire small bowel and colon Whiteford (2013) suggests that colorectal incisions are was noted. This, again, was thought to be secondary to described as clean contaminated and the incidence of a a low flow state from her severe cardiomyopathy. The superficial infection is 5%–10%. family was notified of the situation and that these findings would be incompatible with survival. They elected Risk Factors to pursue comfort care measures. The patient expired Risk factors include age greater than 60 years, diabetes shortly thereafter. mellitus, malnutrition, immunosuppression, fecal contamination, intraoperative hypothermia, extensive sur- Anastomotic Bleeding/Hemorrhage gery, prolonged length of hospital stay prior to surgery, Anastomotic bleeding is common and usually self- and the American Society of Anesthesia score greater limited; however, anastomotic hemorrhage is infre- than 2. Postoperative infections usually occur around quent, occurs in 0.5%–1% of cases, and will usually the fifth postoperative day. stop spontaneously ( Ruis-Tovar et al., 2010). A small amount of intra-abdominal bleeding is normal after Signs and Symptoms colorectal surgery and is easily reabsorbed within the Signs and symptoms of a wound infection include ery- peritoneum if no infection is present. Surgery is indi- thema, tenderness, drainage, induration, fever, and cated for a large or continuous hemorrhage. tachycardia. The infection may manifest as cellulitis, an abscess, or both. If a fluid collection is found, the Risk Factors area is opened and drained. A culture can be obtained Risk factors for anastomotic bleeding/hemorrhage are to help determine sensitivity if antibiotic treatment is most often related to tension at the anastomosis, sta- necessary such as in the case of cellulitis. pler malfunctions during surgery, ischemia, or poor technique of the surgeon. Other factors that are patient Treatment related include radiation exposure, malnutrition, Most often, opening the wound and allowing it to heal immunosuppression, obesity, and local sepsis. by secondary intention with packing or wound vacu- um placement is all that is necessary ( Whiteford , Signs and Symptoms 2013). Necrotizing wound infections most often devel- Signs and symptoms of hemorrhage are tachycardia, op the first couple of days after surgery and may be the decrease in urinary output, hypotension, and decrease result of Clostridium perfringens or beta-hemolytic in hemoglobin with or without obvious signs of bleed- Streptococcus , which could be potentially life- ing because hemorrhage may be intra-abdominal and threatening. The wound is usually very painful and a may lead to abdominal distention. thin gray drainage is present. These patients are taken back to the OR for wound debridement and broad- Treatment spectrum antibiotics with high-dose penicillin are given Management of bleeding begins with supportive care intravenously ( Dietz , 2011). to maintain hemodynamic stability including replace- A project known as the Surgical Care Improvement ment of intravascular volume with crystalloids and Project was developed to help decrease the incidence of colloids along with transfusion of packed red blood surgical site infections in colorectal surgery patients. cells, plasma, and platelets. More severe bleeding is This improvement project measures appropriate use of managed with epinephrine and saline retention ene- antibiotics, administration of antibiotics within 1 hour mas. If the cause of the hemorrhage is found to be a of incision, cessation of antibiotics within 24 hours of contained hematoma, surveillance is indicated, the surgery, and maintenance of patient normothermia hematoma will most often spontaneously reabsorb, during surgery. The efficacy of this project has been and no surgical intervention is necessary ( Dietz , 2011; debated and is an ongoing project ( Dietz , 2011). Ruis-Tovar et al., 2010). If there is no indication of infection, a drain may be inserted to help drain the Wound Dehiscence hematoma, especially in patients who are elderly or are Wound dehiscence, or the opening of a surgical wound poor repeat surgical candidates. However, if with fascia intact, occurs in 0.5%–3% of all abdomi- the patient becomes hemodynamically unstable or the nal surgeries and is associated with up to a 20% mor- hematoma enlarges (a sign of active bleeding), the tality rate as reported by Oncel and Remzi (2003). patient is taken immediately to the OR for exploratory Wound dehiscence is caused by tissue necrosis, sutures laparotomy ( Dietz , 2011; Ruis-Tovar et al., 2010). tied too tightly or placed too close to the edge of the

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SSGA200343.inddGA200343.indd 374374 226/09/136/09/13 8:068:06 PMPM The Ileus and Oddities After Colorectal Surgery

wound, or wound disruption caused by increased ing care with a particular awareness of the potential intra-abdominal pressure. negative outcomes related to colorectal surgery can An increase in intra-abdominal pressure may be make the difference in quick diagnosis and manage- caused by edema or ischemia of the intestines, intra- ment of untoward complications. ✪ abdominal abscess or infection process, shock, positive pressure ventilation, prolonged surgical time, and large REFERENCES volume transfusions. This, in turn, leads to cardiac, American Society of Colorectal Surgeons . (1996 ). Mortality rates renal, and pulmonary function failure, which affects for colorectal specialists (Press release). Retrieved June 3, 2013, the splanchnic circulation and leads to abdominal from http://cccrs.tripod.com/MortBetter.html compartment syndrome and decreased blood flow to Ansari , P. (2012, November). Intestinal obstruction. Merck Manual . the abdominal wall ( Oncel & Remzi , 2003). Retrieved June 3, 2013, from http://www.merckmanuals.com/ professional/gastrointestinal_disorders/acute_abdomen_and_ If the patient is suspected of having an increase in surgical_gastroenterology/intestinal_obstruction.html intra-abdominal pressure, primary closure of the Boushey , R. , & Williams , L. J. ( 2013 , March 13). Management of abdominal wall is avoided. The wound is left open anastomotic complications of colorectal surgery . Retrieved June with application of wet-to-dry dressings and a delayed 3, 2013, from http://www.uptodate.com/contents/management- wound closure is planned. Retention sutures may be of-anastomotic-complications-of-colorectal-surgery used if the only concern is wound dehiscence with no Cagir , B. ( 2013 ). Ileus . Medscape Reference . Retrieved July 28, 2013, indication of increase in intra-abdominal pressure from http://emedicine.medscape.com/article/178948-overview ( Oncel & Remzi, 2003). Dang , C. V. , & Giebel , J. (2013 , February 22). Acute mesenteric ischemia treatment and management. Medscape Reference . Retrieved September 13, 2013, from http://emedicine.medscape Wound Evisceration .com/article/189146-treatment#aw2aab6b6b3 Wound evisceration or opening of a wound with open- Dietz , D. W. ( 2011 ). Complications in colorectal surgery . Retrieved ing of fascia and protrusion of the abdominal organs June 3, 2013, from http://www.fascrs.org/physicians/education/ occurs in approximately 2% of all abdominal surgeries core_subjects/2011/Complications/' and is more often noted in elderly or obese patients. Hocevar , B. J. , Robinson , B. , & Gray , M. ( 2010 ). Does chewing gum Evisceration is related to other complications such as shorten the duration of postoperative ileus in patients under- wound infections, wound hematomas, ileus, and fis- going abdominal surgery and creation of a stoma ? Journal of tula formation ( Ruis-Tovar et al., 2010). Once a Wound Ostomy & Continence Nursing, 37 ( 2 ), 140 – 146 . wound evisceration is confirmed, the patient is returned Mayo Clinic . ( 2012 , December 18). Intestinal obstruction . Re- trieved June 3, 2013, from http://www.mayoclinic.com/health/ to surgery for repair of the opening and placement of = retention sutures ( Ruis-Tovar et al., 2010). intestinal-bstruction/DS00823/DSECTION causes National Digestive Diseases Information Clearinghouse. (2013). Intestinal pseudo obstruction. Retreived from http://digestive Conclusion .niddk.nih.gov/ddiseases/pubs/intestinalpo/#what Complications of colorectal surgery continue to be an Oncel , M. , & Remzi , F. H. (2003 ). Perioperative complications in existing concern and, at times, make diagnosis difficult colorectal surgery. Clinics in Colon and Rectal Surgery, 16 ( 2 ), because of the presentation of complications mimick- 143 – 152 . ing one another. This, in turn, can result in the inabil- Ruis-Tovar , J. , Morales-Castinerias , V. , & Lobo-Martinez , E. ( 2010 ). Postoperative complications of colon surgery. Cirugía y Ciruja- ity to diagnose and treat complications in a timely nos, 78 ( 3 ), 281 – 288 . manner and subsequently affects patient outcomes. Senagore , A. J. ( 2007 ). Pathogenesis and clinical and economic con- Limiting or avoiding risk factors for such complica- sequences of postoperative ileus . American Journal of Health- tions as well as having experienced colorectal surgeons System Pharmacy , 64 ( 20, Suppl. 13 ), S3 – S7 . provide appropriate surgical interventions will not Whiteford, M. H. (2013 ). Early complications in colorectal surgery. Retrieved only improve outcomes but also bring forth an overall June 3, 2013, from http://www.fascrs.org/physicians/education/core_ decrease in mortality and morbidity rates. Astute nurs- subjects/2007/colorectal_surgery_early_complications/

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