I often get asked about bowel movements after colon or abdominal surgery, so I decided to address the issue on my blog. In any surgery that involves making an incision in the abdomen, the bowels need to be moved or packed out of the way to get to the organ of interest. The small bowels are free-floating in the abdomen and are generally the first structure to be encountered in abdominal surgery. Once the bowel is manipulated during surgery,  its normal migratory pattern also known as peristalsis is temporarily altered. The movement of the bowels become dyscoordinated and ineffective. What this means to you is that the bowel does not move gas or liquid through and bowel contents can accumulate in the stomach. Air and fluid in the stomach can cause hiccups, nauseau, and sometimes vomiting. In anywhere from two to seven days, the bowel regain their normal motility pattern and begin to move things through and produce a bowel movement.

Some things that your surgeon may do while your "stunned" bowels are recovering is to  place a nasogastric or NG tube. This tube which goes from your nose to your stomach suctions out the accumulated fluid out of your stomach. Keeping your stomach empty and preventing its overdistention can alleviate the nauseau and hiccuping that can occur. You will often be maintained on IV fluids to keep you hydrated. And most importantly, but often the most discomforting for patients is that you will be kept NPO (nothing per os) meaning you will not be allowed to eat or drink anything except for maybe an ice chip or two and perhaps a sip of water. Bowel rest is needed to allow your intestines to recover. In addition, if you attempt to eat or drink anything, you will often vomit because the bowels are not moving things through. Patients will often ask where does this fluid and air come from when you are fasting. Believe it or not, even during fasting the bowels produce approximately one to two liters of fluid a day.  Also, we swallow air regularly while talking, swallowing saliva, etc. Air is often the way your surgeon knows that your bowels have recovered and it is safe for you to start eating. As mentioned earlier, air is swallowed on a regular basis often while talking. That air enters your stomach and works its way through the small and eventually large bowel. It emerges as a "fart" once your bowels have regained their full function after colon surgery. Air will usually precede a bowel movement and signals to your surgeon that you can start oral intake, usually in the form of clear liquids: soup, jello, etc, followed by solid food. Patients often view fasting as a bigger insult to them than the incision they have on their belly, but most Americans can generally tolerate not eating for up to a week. Bowels generally "wake up" between two to seven days, but can in certain situations take longer. Delayed return of bowel function can occur due to a history of multiple surgeries, Inflammatory bowel disease, i.e. Crohn's Disease and Ulcerative Colitis, a large hematoma, abscess,  or scar tissue. A computed tomography (CT) scan of the abdomen can often help elucidate the problem. TPN (total parenteral nutrition) is an intravenous (IV) solution of nutrients and minerals that can be given during periods of prolonged bowel rest, usually greater than one week.

Nothing has been proven definitively to stimulate the bowels to wake up faster, however some studies have suggested that early ambulation (getting up and wlking around) and chewing gum or hard candies helps stimulate the return of bowel function after surgery.

 

This is based on a study performed by two researchers out of Boston. Dr. Peter Lee and Dr. Atul Gawande, bestselling author, analyzed hospital and ambulatory center data provided by the Agency of Healthcare Research and Quality. The hospital data acquired in 2002 were collected from three representative states: Colorado, Florida, and New Jersey. The researchers assumed an average lifespan of 85 years. This study is the first of its kind to quantify the average number of surgeries the average American will undergo in his or her lifetime.  The three states had similar numbers in terms of the number of surgeries done in that year. There were some regional variations in the types of procedures. For example, Colorado had a significantly higher number of orthopedic procedures than in the other two states. In this startling finding, it was found that six of those procedures will be done in a hospital operating room, while the remaining three are done as an outpatient. The study also highlights that the traditional notion of surgery is also changing. A number of those procedures are done by nonsurgeons such as cataract surgery by ophthalmologists and coronary stent placement by cardiologists. So while the overall number of surgery is fairly large, the trend is toward minimally invasive surgery. The number of surgeries, not surprisingly, increases with age. Women's reproductive years are associated with an increase in the number of surgeries as are the years between 45 and 75 for both men and women. Not surprisingly, three of the top ten most common procedures for women are on the reproductive organs. The top ten most common procedures were stratified according to gender. For men, the top ten procedures included: percutaneous transluminal coronary angioplasty, wound debridement, inguinal and femoral hernia repair, lens and cataract procedures, coronary artery bypass graft (CABG), knee arthroplasty, procedures on muscles and tendons, peripheral vessel procedures, cholecystectomy (gallbladder surgery), and transurethral procedures. For women, cesarean section ranked as the most common procedure. The following procedures round out the top ten: cholecystectomy, lens and cataract procedures, breast lumpectomy, wound debridement, percutaneous transluminal coronary angioplasty, knee arthroplasty, diagnostic dilatation and curettage, hip replacement, and procedures on muscles and tendons. The authors in their October 2008 presentation at the annual meeting of the American College of Surgeons in San Francisco, California were reluctant to make any health policy recommendations based on their data, citing the fact that the data was drawn from 2002. The number of surgeries may have increased since then, particularly the minimally invasive procedures. Nonetheless, it does give us some insight into how our health care dollars are being spent and will be spent in the future.

Abdominal aortic aneurysms (AAA) are life-threatening in that all aneurysms have a risk of rupture. Rupture risk is mostly dependent on size of the aneurysm. Many people who are told that they have a AAA feel like they have been told that they have a ticking time bomb in their belly. One study conducted by Dr. Brian Nolan from Dartmouth-Hitchcock Medical Center found that nearly half of all patients undergoing surveillance for their abdominal aortic aneurysm reported feeling anxious since their diagnosis. Almost all patients will ask what they can do to reduce their risk of rupture. In Dr. Nolan's study, 30% modified their lifestyle by limiting their activities for fear that physical exercise can induce rupture. The truth is no on really knows how much physical activity is safe. The reality is that aneurysms take years to develop, so suddently altering your lifestyle is unlikely to change the rupture risk at all. In addition, patients that come in with a ruptured aneurysm rarely say that their abdominal pain was preceded by a bout of physical activity or heavy lifting. There are some studies that suggest that better blood pressure management with beta-blockers and ace-inhibitors reduces the rupture risk of aneurysm. But there is not yet enough data to make any firm guidelines on blood pressure management for people with aneurysms. Another notable finding of Dr. Nolan's study is that despite a rupture risk of 4%, many of the respondents in his study reported that their rupture risk was 22%. The higher the rupture risk the respondent quoted, the more likely they were to report feeling anxious. I have been asked on several occasions as well if it is okay to get a stress test when you have an aneurysm. Stress test "stress" the heart by elevating the heart rate to see how the heart responds. The heart rate increase is only temporary. Once you have been given a diagnosis of a AAA, the best thing you can do is maintain a healthy diet, continue with low-impact exercise, and watch your blood pressure and exercise. And, keep your doctor appointments. The famous actor, George C. Scott, died of a ruptured abdominal aortic aneurysm because he ignored a diagnosis of a AAA made years earlier.

A group of Canadian anesthesiologists conducted a study to find the answer to this question and presented their data at the 2008 annual meeting of the Canadian Anesthesiologists' Society. They studied 95 male patients who were scheduled for colorectal resection. The men were divided into two groups based on their exercise plan. The simple exercise group walked and performed breathing and leg exercises. The complex exercise group added weight training and stationary cycling to their regimen. The exercise time period ranged from three to six weeks. After surgery, the men who showed improved physical conditioning from their exercise regimen were able to walk an average of 7.8% farther after surgery than they did at baseline. The surprising finding of the study was that no differences were found in terms of results between patients in the complex and simple exercise programs. This is encouraging news for those who want to participate in "prehabilitation" but fear that they cannot fully engage in a rigorous exercise program.

The study findings were in accordance with the general notion that the better physical condition, one is in; the better one does after surgery. Walking is an important part of postoperative recovery. It is important for patients to get out of bed as early as possible to prevent the formation of blood clots in the legs and to be in an upright position to better cough and clear out secretions that could lead to pneumonia.  With joint replacement surgery and open heart surgery, rehab and physical therapy is often begun while the patient is still in the hospital. But as with all things, how well a person recovers after surgery is predicated on a number of factors as well. One thing the researchers did not factor in was how exercise in conjunction with nutrition impacted patient's postoperative recovery. With abdominal surgery, where patients often cannot eat for up to one week post surgery, adequate nutritional stores and protein reserves are necessary to maintain the patient during this fasting state. Even if allowed regular food post surgery, many patients often complain of decreased appetite and eat little. Studies have shown that malnourished patients do not do as well after surgery as those with good nutrition stores.

Interestingly, the study showed that  patients over 75 years of age experienced less benefit from the exercise program than those under the age of 50, as did those with a body mass index (BMI) above 30, considered the threshold for obesity, compared with patients whose BMI was below 25. More study is needed to determine how those groups can best benefit from a presurgery exercise program.

Barbara Bush is recovering from abdominal surgery this morning. She had been experiencing abdominal pains for the last few days and went to the hospital Tuesday night for evaluation. Initial reports from the White House claimed that she went for a routine checkup of a several month history of abdominal pain. Her evaluation was said to be negative and she would be discharged from the hospital this morning. It is a little unusual for someone to seek routine evaluation first at night, and secondly in a hospital as opposed to during the day at their physician's office. The truth came out in a  statement released by the hospital this morning  which said the former First Lady "underwent routine, laparoscopic surgery Tuesday night to correct a perforated ulcer. She was resting comfortably Wednesday morning, and visiting with her family."

"During the procedure last night, surgeons cleansed her abdominal area, then patched and closed a one-centimeter hole in Mrs. Bush's stomach, caused by the ulcer," the statement said. "Mrs. Bush is expected to be discharged from the hospital next week." President Bush in his annual Thanksgiving pardoning of a turkey stated that he was thankful his mother was doing well after surgery. Barbara Bush is 83 years old and otherwise healthy. She revealed a diagnosis of Grave's Disease while her husband was in the White House.

According to Sanjay Gupta of CNN, an abdominal Xray was performed which revealed that air was seen on the xray. Air visible on an xray indicates that it had escaped through a hole in the intestine A hole in the intestine is dangerous and must be treated with surgery immediately. Stool, or intestinal contents, can exit this hole into the abdominal cavity causing a severe infection if untreated. Patching, closes the hole, allowing the bowels to heal. She will likely be in the hospital for a week. She will not be allowed to eat for several days requiring intravenous fluids for hydration. She will most certainly need antibiotics for a short time. It is difficult to discern at this time her prognosis given the limited information we are receiving. Her recovery is dependent on the time interval between her perforation and her treatment. In addition, since she was able to have minimally invasive laparascopic surgery which uses multiple small incisions as opposed to one large one, she should have less pain. Since she is a relatively healthy 83 year old, she will probably do just fine.

For information on peptic ulcer disease:
http://www.aafp.org/afp/20071001/1013ph.html
http://www.acg.gi.org/patients/gihealth/peptic.asp
http://www.gastro.org/wmspage.cfm?parm1=5686

For information on laparascopic surgery for anti-reflux disease
http://www.sages.org/publication/id/PI01/