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ORIGINAL ARTICLE
Year : 2015  |  Volume : 3  |  Issue : 1  |  Page : 1-6

Factors affecting bowel motility following abdominal surgery: A clinical study


Department of Surgery, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India

Date of Web Publication23-Mar-2015

Correspondence Address:
Atul Saxena
Department of Surgery, Era's Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.153799

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  Abstract 

Background: Postoperative ileus (POI) is a common complication of many surgical procedures. It is generally defined as a cessation of bowel motility. The pathogenesis of POI is multifactorial with bowel dysmotility being caused by disturbances in immunologic, inflammatory, neurologic, electrolyte and receptor-mediated functioning. Materials and Methods: Between January 2013 to June 2014, 140 patients with elective abdominal surgery were included in the present prospective study. The factors that were studied to see their effect on the return of bowel motility are type of surgery, duration of surgery, handling of bowel and electrolytes level. Results: It was found that these factors were significantly associated with POI. Out of the 140 patients enrolled in the study, appearance of bowel motility within 4 days was in 126 (90.00%) while after 4 days in only 14 (10.0%) patients. Discussion: This study showed that POI was an undeniable complication of abdominal surgeries; however, it was dependent on a host of factors, including age, type of surgery, category of bowel handling, duration of surgery and electrolyte imbalance. Although most of these are unmodifiable risk factors, however, a skilful handling, selection of appropriate operative technique and fluid management could help to reduce this complication.

Keywords: Abdominal surgeries, electrolytes, postoperative ileus


How to cite this article:
Saxena A, Mahendru V. Factors affecting bowel motility following abdominal surgery: A clinical study. Saudi Surg J 2015;3:1-6

How to cite this URL:
Saxena A, Mahendru V. Factors affecting bowel motility following abdominal surgery: A clinical study. Saudi Surg J [serial online] 2015 [cited 2022 Dec 3];3:1-6. Available from: https://www.saudisurgj.org/text.asp?2015/3/1/1/153799


  Introduction Top


Postoperative ileus (POI) is a common complication of many surgical procedures. Although it can be a complication of any major surgical procedure yet it is most commonly associated with abdominal surgery. [1] Despite numerous advances in surgical technique and perioperative care, POI continues to be one of the most common and expected aspects of abdominal surgery. A number of researchers believe that POI is a mandatory phase of the recovery period for any intra-abdominal procedure, and only an ileus lasting >5 days is abnormal - to be termed a prolonged POI (PPOI). [2],[3],[4] In the present study, we intend to study the prevalence of POI as an indicator of deviation in bowel motility and to assess role of various risk factors associated with occurrence and progression of POI using a prospective study design in patients undergoing abdominal surgeries at a tertiary care center.


  Materials And Methods Top


Study design

The present study was carried out as a prospective cross-sectional observational study.

Settings

The study was carried out at Department of Surgery, Era's Lucknow Medical College and Hospital, Lucknow. Era's Lucknow Medical College and Hospital is a tertiary care center with state-of-the-art infrastructure catering primarily to socio-economically underprivileged suburban and rural population of Lucknow.

Duration of study

Eighteen months starting from January 2013 to June 2014.

Sampling frame

The sampling frame of the study was bound by the following inclusion and exclusion criteria:

Inclusion criteria

All patients with elective abdominal surgery will be included in the study irrespective of the cause.

Exclusion criteria

Patients with any of the following conditions were excluded from the study:

  • Age <18 years
  • Patient with previous surgery
  • Patients with serious co-existing injuries besides gastro-intestinal injuries, which would add to the morbidity and mortality.
Sample size

The sample size for the study was worked up at Department of Community Medicine, Era's Lucknow Medical College and Hospital, Lucknow using the following illustration:

Sample size is calculated using the formula

Where P = 43% incidence of POI

q = 100-p

Type I error = 5%

Allowable error L = 20% of p

Then,

n = 127 + (10% of data loss)

=140

All patients undergoing elective abdominal surgery between January 2013 to June 2014 at Department of Surgery, Era's Lucknow Medical College and Hospital, Lucknow were prospectively followed-up in the postoperated period to document the incidence of POI. The return of bowel function was assessed on the basis of appearance of peristaltic sound, passage of flatus and feces, tolerance of oral feeds. Clinical diagnosis of POI can be established by a history of worsened postoperative pain, nausea and vomiting, anorexia, abdominal bloating, abdominal distension, lack of passage of flatus or stool, delay in resuming enteral nutrition, and prolonged hospitalization. This was further be confirmed with an abdominal X-ray in erect and supine position showing generalized distension of the bowels with presence of air shadow in the distal colon/rectum.

The following factors were studied to see their effect on the return of bowel motility. These are:

  • Type of surgery
  • Duration of surgery
  • Handling of bowel
  • Electrolytes.
Type of surgery

The term abdominal surgery broadly concerns surgical procedures that involve opening up of the abdomen. In this study, surgery was classified as laparoscopic and open surgery.

Duration of surgery

Total duration of surgery was noted to the nearest minute.

Handling of bowel

It was intuitive that GI tract dysfunction after intraabdominal surgery might occur as a direct result of bowel manipulation. Handling of bowel was categorized into two groups:

  • Category I: Surgery with minimal bowel handling such as appendicectomy, hysterectomy, lap cholecystectomy, etc
  • Category II: Surgery with maximal bowel handling such as perforation peritonitis, resection anastomosis, exploratory laparotomy etc.
Electrolytes

Electrolytes studied in this study were serum sodium, potassium. Level, that is, preoperative as well as daily postoperative levels for 3 days also.

All patients were evaluated preoperatively, intra operatively, and postoperatively.

After the bowel sounds appear, Ryle's tube was removed and oral diet was started (which gradually was followed by full oral diet).

Bowel sounds were auscultated in five quadrants (umbilical, left and right lumbar, epigastrium and hypogastrium) of the abdomen for 2 min.

On discharge, patients were advised to take small frequent meals, to avoid spicy food, not to smoke, avoid alcohol. H 2 -receptor blockers/protein pump inhibitor were advised for 6 weeks.


  Result Top


The present study was conducted in the Department of Surgery at Era's Lucknow Medical College and Hospital, Lucknow to study the incidence of POI in patients undergoing elective as well as emergency abdominal surgery and to study role of type/duration of surgery, handling of bowel and electrolyte levels affecting bowel motility during postoperative period. All patients with elective abdominal surgery were included in the study irrespective of the cause. Hence, first 140 patients fulfilling the inclusion criteria and not coming in the domain of exclusion criteria were enrolled for the study and were prospectively followed-up in the postoperated period to document the incidence of POI. As it is believed that POI is a mandatory phase of the recovery period for any intra-abdominal procedure and bowel motility coming within 4 days was considered as normal and >4 days was considered as abnormal, on the above basis the patients were distributed as under [[Table 1]].
Table 1: Distribution of patients according appearance of bowel motility (n=140)

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Of the 140 patients enrolled in the study, appearance of bowel motility within 4 days was in 126 (90.00%) while after 4 days in only 14 (10.0%) patients.

Age of patients of Group I ranged from 20 to 58 years while that of Group II ranged 32-53 years. In Group II, none of the patients were aged <30 years as compared to 32 (25.4%) in Group I. Mean age of patients in Group I was 36.88 ± 8.98 years as compared to 40.29 ± 6.81 years in Group II. Statistically, there was a significant difference between two groups with respect to age (P = 0.032).

Proportion of Males in Group II (57.14%) was found to be higher than that found in Group I (53.97%), but this difference was not found to be statistically significant (P = 0.821) [[Table 2]].

In Group I patients, most common diagnosis was cholelithiais (38.10%) while in Group II most common diagnosis were cholelithiasis (21.43%) and common bile duct (CBD) stricture (21.43%). Proportion of patients with appendicitis, Ca colon, Ca ovary, Ca stomach, cholelithiasis, ileostomy in situ, Inguinal hernia, Incisional hernia, pancreatic pseudocyst, umbilical hernia and ventral hernia was found to be higher in Group I as compared to Group II while proportion of patients with CBD stricture, choledochal cyst, choledocholithiasis, Intestinal obstruction, Koch's abdomen and ulcerative colitis were higher in Group II.
Table 2: Between group comparison of diagnosis of study population

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In both the groups, upper abdomen, was more commonly involved (65.9% and 71.4%) as compared to lower abdomen (34.1% and 28.6%) respectively.

Most common operative procedure in Group I was lap cholecystectomy (27.78%) followed by hernioplasty (11.11%) and open cholecystectomy (10.32%). In Group II most common operative procedures were hepatico jejunostomy, Laparotomy with resection and anastomosis and Open cholecystectomy (21.43% each), followed by choledochojejunostomy and choledocholithotomy (14.29% each).

A statistically significant difference in operative procedures of both the groups was found (P < 0.001).

Handling of bowel was categorized in two groups:

  • Category I: Surgery with minimal bowel handling such as appendicectomy, hysterectomy, lap cholecystectomy etc
  • Category II: Surgery with maximal bowel handling such as resection anastomosis, exploratory laparotomy etc., [[Table 3]].
Minimal bowel handling surgery (Category I) was done in higher proportion of patients of Group I (74.60%) as compared to Group II (35.71%) and maximal bowel handling surgery (Category II) was done in higher proportion of Group II (64.29%) as compared to Group I (25.40%).
Table 3: Between group comparison of handling of bowel category in study population

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Difference in bowel handling of both the groups was found to be statistically significant (P = 0.002) [[Table 4]].
Table 4: Between group comparison of duration of surgery in study population

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Duration of surgery in Group I ranged between 30 and 140 min with a mean value of 65.12 ± 25.24 min (median: 60.00 min). Duration of surgery in Group II ranged between 45 and 150 min with a median of 97.50 min and mean 98.57 ± 33.94 min. Duration of surgery in Group I was found to be lower than that of Group II and this difference was found to be statistically highly significant (P < 0.001).

Baseline systolic blood pressure (SBP) of Group I (124.72 ± 6.89 mmHg) was found to be higher than that of Group II (124.14 ± 6.63 mmHg) but this difference was not found to be statistically significant (P = 0.765; NS).

Baseline diastolic blood pressure (DBP) of Group I (81.44 ± 5.40 mmHg) was found to be lower than that of Group II (82.29 ± 6.27 mmHg) but this difference was not found to be statistically significant (P = 0.587).

Baseline pulse rate of Group II (76.57 + 8.68/min) was found to be higher than that of Group I (75.08 ± 5.73/min) and this difference was not found to be statistically significant.

Baseline serum potassium levels of Group I were found to be 3.90 ± 0.22 and that of Group II 3.89 ± 0.33. Baseline serum potassium levels of Group I was found to be higher than that of Group II but this difference was not found to be statistically significant (P = 0.029).

At all the time periods mentioned above Serum potassium levels of Group I were found to be higher than that of Group II with a statistically significant difference at all the above time periods.

Baseline serum sodium levels of Group I (139.02 ± 2.02) was found to be higher than that of Group II (137.57 ± 3.37) and this difference was found to be statistically significant (P = 0.020).

At all the time periods mentioned above Serum sodium levels of Group I were found to be higher than that of Group II with a statistically significant difference at all the above time periods.

Duration of passage of flatus in Group I (2.10 ± 1.04 days) was found to be lower than that of Group II (5.71 ± 0.73 days) and this difference was found to be statistically significant (P < 0.001).

Duration of passage of feces in Group I (3.17 ± 0.92 days) was found to be lower than that of Group II (6.57 ± 0.76 days) and this difference was found to be statistically significant (P < 0.001).

Though preoperative abdominal distension was observed in higher proportion of Group II (21.43%) as compared to Group I (7.14%) but this difference was not found to be statistically significant (P = 0.070).

Postoperative abdominal distension was observed in higher proportion of Group II (100.0%) patients as compared to Group I (5.56%) and this difference was found to be statistically significant (P < 0.001).

In Group I change in abdominal distension from preoperative to postoperative period was not found to be statistically significant. Contrary to this, this difference in Group II was found to be statistically significant (P < 0.001).

Preoperative abdominal rigidity was observed in higher proportion of Group I (9.52%) as compared to Group II (7.14%) but this difference was not found to be statistically significant (0.771).

Postoperative Abdominal rigidity was observed in higher proportion of Group II (28.57%) patients as compared to Group I (1.59%) and this difference was found to be statistically significant (P < 0.001).

Change in abdominal rigidity from preoperative to postoperative stage in Group I was found to be statistically significant (P = 0.006) but in Group II was not found to be statistically significant (P = 0.139).


  Discussion Top


Abdominal surgery is a transitory condition during which the abdominal functions are stalled purposively for a specified period of time in order to facilitate the surgical procedure. However, the primary focus of a surgeon is to restore the abdominal functions to normal routine within the minimum possible time. Passing of flatus is one of the important functions of that is impaired during and after the abdominal surgery.

It has been often seen that postoperative bowel motility is delayed without any tangible functional complication and is intriguing for the surgeon as well as the patient. Hence, systematic efforts to understand the factors responsible for this delay, that is, POI have been made by numerous researchers over the time. It has been shown that POI has a multifactorial pathogenesis [5] that is governed by both patient as well as procedural/infrastructural characteristics.

Keeping in view this background, the present study was planned with an aim to study the incidence of POI in patients undergoing elective abdominal surgery and to find out factors responsible for this. For this purpose a prospective observational study was carried out in which a total of 140 patients fulfilling the inclusion criteria and not coming in the domain of exclusion criteria were enrolled for the study and were prospectively followed-up in the postoperated period to document the incidence of POI and to find out the factors responsible for it.

Postoperative ileus (>4 days) was observed in 14 out of 140 cases, thus showing the prevalence of POI to be 10% only. Prevalence of POI has been reported to follow a wide range depending on type of procedure and criteria for defining POI. The prevalence is lower in surgeries not involving abdomen and being performed laparoscopically. In present study, the rate of POI was close to that reported by Kim et al. [6] and Kronberg et al. [7]

With respect to age and gender, we found a significant association of age with POI. It was observed that advancing age was a risk factor for PPOI. This finding is in consistence with the observation made by Vather and Bissett [8] however, Kim et al. [6] who also explored the role of age with PPOI did not find this association to be significant. In present study, we did not find an association between gender and POI. However, a number of studies have shown association of male sex with increased risk of PPOI. [9],[10],[11]

In present study, majority of procedures were carried out in upper abdomen (upper gastrointestinal tract and surrounding viscera) (n = 93/140; 66.43%). However, no significant association between location of abdomen being accessed and POI was observed. One must not forget that PPOI is not confined to abdominal surgeries only, and despite the fact that the responsive gastrointestinal system being located in abdomen, it is affected by other peripheral surgeries too. [10],[12] In an animal model, it has been shown that inhibition of gastrointestinal transit starts from the time of skin incision itself, thus showing that the pathogenesis of PPOI does not involve local stimulation only. [13]

In present study we found that type of operative procedure has a significant association with PPOI. In present study, procedures like hernioplasty, ileostomy closure, those involving laparoscopic procedures, open appendectomy and open cholecystectomy were some of the important procedures that did not have a single case of PPOI. However, among cases having PPOI, hepaticojejunostomy, laparotomy with resection and anastomosis and open cholecystectomy were the major contributors.

In present study, we categorized different types of surgeries in terms of category of bowel handling. The significance of bowel handling has been reported to reducing intra-operative complications and operating time. [14] We found a significant association between PPOI and category of bowel handing during a particular abdominal surgery procedure. It was observed that patients in whom PPOI took place had a significantly higher proportion of patients with procedures having category II of bowel handling and vice versa.

In present study, time of operative procedure ranged from 30 to 150 min. It was observed that mean time taken in surgery was significantly lower in patients in whom PPOI did not occur (65.12 ± 25.24 min) as compared to that in patients in whom PPOI happened (98.57 ± 33.94). A significant association between duration of surgery and time taken for toleration of clear liquids and time to first bowel movement or flatus and toleration of a regular diet. [15]

In present study, mean postoperative electrolyte levels (S. potassium and S.sodium) were found to be significantly lower throughout the evaluation period (120 h) in PPOI group as compared to those in whom PPOI did not occur. An explanation for electrolyte deficiency in PPOI was provided by Prasad et al.(1999) [16] who reported that deficiencies of magnesium and potassium are commonly associated with fluid shifts between physiologic compartments and may prolong POI. Fineberg et al. [11] in their study also reported an independent predictive role of fluid/electrolyte disorders in causation of PPOI. Postoperative electrolyte laboratory values should be proactively and routinely monitored; deficient electrolytes should be aggressively treated to established normal values. [17]

In the present study, day 4 postoperative abdominal distension and rigidity proved to be significantly associated with POI. Day 4 abdominal distension and rigidity could be considered as a manifestation of POI.


  Conclusions Top


The present study showed that POI was an undeniable complication of abdominal surgeries, however, it was dependent on a host of factors, including age, type of surgery, category of bowel handling, duration of surgery and electrolyte imbalance. In majority (90.0%) and of study population (n = 140) postoperative gastric motility was within 4 days (Group I) and only 14 (10.0%) had postoperative gastric motility after 4 days (Group II). A statistically significant difference in operative procedure and bowel handling of Group I and Group II patients was observed (P = 0.004). Duration of surgery in Group I (65.12 ± 25.24 min) was significantly lower than that of Group II (98.57 ± 33.94 min). No statistically significant difference in hemodynamic variables (SBP, DBP, pulse rate) of patients of Group I and Group II was observed. Difference in Baseline Serum potassium level of Group I and Group II patients was not found to be statistically significant but difference was found to be statistically significant at all-time intervals from 24 h to 120 h. Difference in baseline serum sodium level of Group I and Group II patients was found to be statistically significant and difference was found to be statistically significant at all-time intervals from 24 h to 120 h.

 
  References Top

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Thompson M, Magnuson B. Management of postoperative ileus. Orthopedics 2012;35:213-7.  Back to cited text no. 1
    
2.
Holte K, Kehlet H. Postoperative ileus: A preventable event. Br J Surg 2000;87:1480-93.  Back to cited text no. 2
    
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Delaney CP. Clinical perspective on postoperative ileus and the effect of opiates. Neurogastroenterol Motil 2004;16:61-6.  Back to cited text no. 3
    
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Sajja SB, Schein M. Early postoperative small bowel obstruction. Br J Surg 2004;91:683-91.  Back to cited text no. 4
    
5.
Vather R, O'Grady G, Bissett IP, Dinning PG. Pathophysiologic, translational and clinical aspects of postoperative ileus - A review. Proc Aust Physiol Soc 2013;44:85-99.  Back to cited text no. 5
    
6.
Kim MJ, Min GE, Yoo KH, Chang SG, Jeon SH. Risk factors for postoperative ileus after urologic laparoscopic surgery. J Korean Surg Soc 2011;80:384-9.  Back to cited text no. 6
    
7.
Kronberg U, Kiran RP, Soliman MS, Hammel JP, Galway U, Coffey JC, et al. A characterization of factors determining postoperative ileus after laparoscopic colectomy enables the generation of a novel predictive score. Ann Surg 2011;253:78-81.  Back to cited text no. 7
    
8.
Vather R, Bissett IP. Risk factors for the development of prolonged post-operative ileus following elective colorectal surgery. Int J Colorectal Dis 2013;28:1385-91.  Back to cited text no. 8
    
9.
Millan M, Biondo S, Fraccalvieri D, Frago R, Golda T, Kreisler E. Risk factors for prolonged postoperative ileus after colorectal cancer surgery. World J Surg 2012;36:179-85.  Back to cited text no. 9
    
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Parvizi J, Han SB, Tarity TD, Pulido L, Weinstein M, Rothman RH. Postoperative ileus after total joint arthroplasty. J Arthroplasty 2008;23:360-5.  Back to cited text no. 10
    
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Fineberg SJ, Nandyala SV, Kurd MF, Marquez-Lara A, Noureldin M, Sankaranarayanan S, et al. Incidence and risk factors for postoperative ileus following anterior, posterior, and circumferential lumbar fusion. Spine J 2014;14:1680-5.  Back to cited text no. 11
    
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Chamberlain RS, Martindale RG. The role of the surgeon and the surgical care team: Proactive strategies for preventing postoperative ileus. Evidence-based management of postoperative ileus. Surg News 2007;1:1-8.  Back to cited text no. 12
    
13.
Kalff JC, Schraut WH, Simmons RL, Bauer AJ. Surgical manipulation of the gut elicits an intestinal muscularis inflammatory response resulting in postsurgical ileus. Ann Surg 1998;228:652-63.  Back to cited text no. 13
    
14.
Kirchhoff P, Clavien PA, Hahnloser D. Complications in colorectal surgery: Risk factors and preventive strategies. Patient Saf Surg 2010;4:5.  Back to cited text no. 14
    
15.
Artinyan A, Nunoo-Mensah JW, Balasubramaniam S, Gauderman J, Essani R, Gonzalez-Ruiz C, et al. Prolonged postoperative ileus-definition, risk factors, and predictors after surgery. World J Surg 2008;32:1495-500.  Back to cited text no. 15
    
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Prasad M, Matthews JB. Deflating postoperative ileus. Gastroenterology 1999;117:489-92.  Back to cited text no. 16
[PUBMED]    
17.
Stollman N, Behmand B. Postoperative ileus. Practical Gastroenterology. 2002:13-23.  Back to cited text no. 17
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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