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46 Nutrition 491
of protein synthesis and degradation reflected in serum protein levels such as albumin (half-life 17 days), transferrin (half-life 8 days), or transthyretin (prealbumin, half-life 48 hrs). In the short term, particularly in the critically ill, nitrogen
balance can be assessed by comparing the amount of nitrogen that is produced in
the urine (24-hrs urine specimen analyzed in the laboratory) with the amount of
nitrogen that is given by nutritional support (written on the package).
So, What Should You Do?
First, decide if nutritional support will be helpful by estimating nutritional
reserve, degree of stress, and time interval to normal diet.
Hold off starting nutritional supplements until perioperative intravenous
fluid resuscitation has attenuated the effect of third-space fluid sequestration and the initial hypermetabolic, hyperglycemic physiologic picture has
abated somewhat (usually within 24 hrs).
Calculate the nutritional requirement by formula (there is no shame in
looking this up) or indirect calorimetry.
Institute nutritional support. Enteral nutritional support should be the first
option. Parenteral nutritional support should be instituted if the nutritional
goals cannot be achieved with enteral support within 7 days.
Closely control the serum glucose with insulin and reassessment every
1–4 hrs.
Measure the effectiveness of treatment by analysis of urinary nitrogen loss
compared with the amount of nitrogen provided by the treatment.
“Routine” Oral Feeding
Fortunately, most of your patients needing emergency abdominal care recover
from the ileus, induced by the underlying disease and its surgical treatment, within a
few days. Traditionally, resumption of oral intake was completed in stages. First, there
was the nasogastric tube, which was kept in situ for variable periods (> Chap. 45);
then, the tube was removed (according to the rules established by the local dogmaguru). After the patient professed the blessed sounds of flatus, the patient was started
on “sips,” thereafter gradually advanced from “clear fluids” to “full fluids” to “soft diet,”
until the great day when “regular diet” was allowed, usually indicating that discharge
home was imminent. Is such a ritual or its variant still practiced in your environment?
If yes, you should know that its value is based on no evidence at all. In fact, there is
scientific evidence to prove that starting the patient on solid feeds is as “safe” and
tolerable as the staged method still practiced by many.
On the other side of the coin, there are surgeons who maintain that a patient
who devours a beefsteak a day after a colectomy is a testimony to their superb
surgical skills. This attitude is probably wrong as well: what is the point of
492 James C. Rucinski
Fig. 46.1. Postoperative day 1: “Let him eat as much as he wants…”
force-feeding a patient who does not have an appetite? The physiological postoperative ileus is a response that must have some purpose; appetite and desire to eat
return when intestinal motility recovers. Our approach is therefore to let the
patient decide when to eat, what to eat, and how much; the patient will tell you
when his or her stomach is ready for a steak or the cornmeal (> Fig. 46.1). But of
course this does not apply to the morbidly obese patient who asks for a giant
pizza an hour after undergoing appendectomy for perforated appendicitis—not
an uncommon scenario in the “fatlands” of northern America.
Concluding Remarks
Before we finish, let us share a few truths with you:
We know that prolonged starvation may be harmful, but there is no definite
proof that early refeeding after surgery is beneficial.
We know that when compared to postoperative TPN, enteral nutrition is
associated with better results. However, in the absence of a nonfed control
group in any of the studies, it is not clear whether enteral nutrition provides specific benefit or that TPN is associated with an increased rate of
complications.
There is some evidence that early postoperative enteral nutrition may
adversely affect respiratory function.
There is some evidence that tight control of hyperglycemia is associated
with a better outcome in the critically ill surgical patient.
46 Nutrition 493
Abdominal catastrophes and their operative treatment are often complicated by compromised nutritional reserve, stress, and a long interval before a normal diet is resumed. The result of these factors is the production of immunoparesis
by autocannibalization of functional protein with associated morbidity and mortality. Nutritional support in selected patients may help to attenuate these effects.
Driven by manufacturers, nutrition hospital services, or “TPN teams,” the current
trend is toward unnecessary overfeeding of the surgical patient—provoking additional morbidity and costs. Artificial feeding is a double-edged sword. Thus, be
selective and cautious.
“Some people never seem able to allow their patients to use the channels designed
by nature to receive nourishment. … Food and fluids given by the alimentary canal allow
the tissues to select and keep what they want, and to reject what is harmful or surplus to
requirements.” (William Heneage Ogilvie, 1887–1971)
“In most conditions, foods that agree with the patients may be eaten, those which
do not, should not be eaten.” (Mark M. Ravitch, 1910–1989)
Reference
Anderson AD, Palmer D, MacFie J. (2003). Peripheral parenteral nutrition. Br J Surg
90:1048–1054.
Postoperative Antibiotics
Moshe Schein
No amount of postoperative antibiotics can compensate for intra-operative
mishaps and faulty technique, and they cannot abort postoperative suppuration
necessitating drainage.
The Issue
Perhaps an issue as apparently banal as postoperative antibiotics does not
deserve a separate chapter. Already in > Chap. 7 you read about preoperative anti-
biotics, and in > Ch ap. 12 you were introduced to the concepts of contamination and
infection and their therapeutic implications. Why not just administer postoperative
antibiotics routinely for any emergency abdominal operation until the “patient is
well”? In fact, this is a common practice in the surgical community in this country
and around the world: patients receive postoperative antibiotics for many days,
many of them are even discharged home on oral agents “just in case”. What is wrong
with this approach? One important problem with this approach is that thoughtless
antibiotic administration has complications that include antibiotic-associated diarrhea, colitis, and the emergence of resistant strains (methicillin-resistant Staphy-
lococcus aureus [MRSA] and Clostridium difficile colitis are major worldwide health
problems). The other problem is cost—not only of the drugs themselves but also of
the expense of administration and the treatment of complications. Our aim is to
convince you that indiscriminate postoperative antimicrobial administration is
wrong and to provide guidelines to approach this issue in a more rational way.
Only recently has the topic of duration of administration been addressed in
the literature; for years, we endured the common laconic recommendation that
antibiotics should be continued until all signs of infection, including fever, leukocytosis, and even ileus subside, and the patient is clinically well. No evidence
existed, however, to prove that indeed the continuation of antibiotics along these
lines could abort an infection-in-evolution or cure an existing one (> Fig. 47.1).
During the last decade, we learned that fever and white cell response are
part of the patient’s inflammatory response to a variety of infective and noninfective causes. We realized that sterile inflammation is common after any operation, manifesting itself as a local inflammatory response syndrome (LIRS) or a
47
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_47, © Springer-Verlag Berlin Heidelberg 2010
495
496 Moshe Schein
Fig. 47.1. “This will cure your fever…”
systemic one (SIRS, systemic inflammatory response syndrome) (> Chap. 54). Is
there a need to administer antibiotics after the bacteria are already dead?
The evolving policy of minimal antibiotic administration (strongly sup-
ported by the Surgical Infection Society; see Mazuski et al. 2002) represents a trend
away from the use of postoperative therapeutic courses of fixed and often long
duration; rather, you should attempt to stratify the infective processes into grades
of risks and to tailor the duration of administration to the severity of infection.
Duration of Postoperative Administration
We recommend the policy summarized in > Table 47. 1. It is based on the
following arguments:
Conditions representing contamination do not require postoperative ad-
ministration since the infectious source has been dealt with at operation; bacteria and adjuvants of infection are effectively removed by the host’s defenses,
supplemented by peritoneal toilet, and adequate tissue levels of pre and intraoperative prophylactic antibiotics. By definition, prophylaxis should not be contin-
ued beyond the immediate operative phase.
In processes limited to an organ amenable to excision ( resectable infec-
tion), the residual bacterial inoculum is small. A postoperative antimicrobial
course of 24 hrs should suffice to sterilize the surrounding inflammatory reaction and deal with gut bacteria, which may have escaped across the necrotic
bowel wall by translocation.
47 Postoperative Antibiotics 497
Table 47.1. Duration of postoperative antibiotic therapy
Contamination: no postoperative antibiotics (assuming appropriate preoperative
prophylaxis administrated)
Gastroduodenal peptic perforations operated within 12 hrs
Traumatic enteric perforations operated with 12 hrs
Peritoneal contamination with bowel contents during elective or emergency procedures
Appendectomy for early or phlegmonous appendicitis
Cholecystectomy for early or phlegmonous cholecystitis
Resectable infection: 24-hrs postoperative antibiotic course
Appendectomy for gangrenous appendicitis
Cholecystectomy for gangrenous cholecystitis
Bowel resection for ischemic or strangulated necrotic bowel without frank perforation
“Mild” infection: 48-hrs postoperative antibiotic course
Intra-abdominal infection from diverse sources with localized pus formation
“Late” (more than 12 hrs) traumatic bowel lacerations and gastroduodenal perforation
with no established intra-abdominal infection
“Moderate” infection: up to 5 days of postoperative antibiotics
Diffuse, established intra-abdominal infection from any source
“Severe” infection: more than 5 days of postoperative antibiotics
Severe intra-abdominal infection with a source not easily controllable (e.g., infected
pancreatic necrosis)
Postoperative intra-abdominal infection
Nonresectable infections with a significant spread beyond the confines of
the involved organ should be stratified according to their severity. A therapeutic
postoperative course of more than 5 days is usually not necessary. However, certain complex situations may need extended courses of postoperative antibiotics.
A typical example is infected pancreatic necrosis, for which the nidus of infection
is not readily eradicated in a once-and-for-all surgical procedure. Similarly, patients with postoperative peritonitis, for which the control of the source of infection is questionable, should be considered for prolonged antibiotic therapy.
498 Moshe Schein
It should be quite clear that the commonplace blind, extended antibiotic
administration for as long as fever or leukocytosis is present should be abandoned. Pyrexia and white cell response usually represent a sterile, peritoneal
(LIRS) or systemic (SIRS), cytokine-mediated, inflammatory response; admittedly, they may on occasions indicate the presence of a focus of persistent or recurrent infection. The former situation is self-limiting and resolves without
antibiotics. The latter usually represents suppurative infection, which should be
treated by drainage of the intra-abdominal abscess (> Chap. 49) or the infected
wound (> Chap. 55). Antibiotic treatment can neither prevent nor treat suppura-
tive infection; it may only succeed in masking it.
By now, you should understand that the persistence of inflammation beyond
the appropriate therapeutic course is not an indication to continue, restart, or
change antibiotics. What should be avoided is complacent reliance on the advice
of the average infectious disease (ID) specialist; this can only lead to an expensive
and often unnecessary diagnostic workup and, even more alarmingly, to the prescribing of the latest antibiotic agent on the market (e.g., “dinnericillin,” “lunchicillin”). What should instead be done first is to stop the antibiotics. The fever will
subside spontaneously in most patients within a day or two with little more than
chest physiotherapy. At the same time, a directed search is undertaken for a treatable source of intra or extraperitoneal infection. Surgeons are best placed to anticipate complications in their patients, and this is what is meant by a directed
search: a search that is conducted with the full knowledge of the patient’s initial
disease process, the operative findings, and the natural history of the surgical
disease—in brief, a corpus of information that usually eludes the ID specialist.
We have nothing personal against the so-called medical ID specialists,
who, at least on this side of the Atlantic, are considered the gurus on antibiotic
therapy. But, we have reasons to believe that many of them do not understand the
concept of “surgical” infection and how it differs from “medical” infection (see
>
Table 47.2).
Table 47.2. Differences between medical and surgical infections
Medical infection (e.g., pneumonia) Surgical infection (e.g., appendicitis)
Not amenable to surgical source control Amenable to surgical source control
Antibiotics mainstay of treatment Antibiotics only an adjunct to source
A host of potential causative organisms Predictable causative organisms
Prolonged formal course of antibiotics Antibiotics tailored to operative findings
control
47 Postoperative Antibiotics 499
So, when was the last time the ID “expert” asked you about your operative
findings? And by the way, in a questionnaire study we asked ID specialists whether
they would recommend obtaining peritoneal cultures during operation for a
“fresh” penetrating wound of the colon; 100% said yes, as if we do not already
know the bacterial composition of s***! So, let them focus on HIV and TB ☺
We hope that you realize that unnecessary antibiotics are wrong because anything unnecessary in medicine is bad medicine. In addition, the price to be paid is
high, not only financially. Antibiotics are associated with patient-specific adverse
effects (the list is long, think of the gravity of C. difficile colitis) and ecological repercussions such as drug-resistant nosocomial infections in your hospital.
Are you convinced?
Start antibiotics prior to any emergency laparotomy; whether to continue
administration after the operation depends on your findings. Know the target
flora and use the cheapest and simplest regimen. The bacteria cannot be confused, and you should not be.
Reference
Mazuski JE, Sawyer RG, Nathens AB, et al. (2002). Surgical Infection Society Guidelines on
antimicrobial therapy for intra-abdominal infections. Surg Infect 3:161–173.
Postoperative Ileus Versus
Intestinal Obstruction
Moshe Schein · Sai Sajja
The postoperative fart is the best music to the surgeon’s ears.
Five days ago, you removed this patient’s perforated appendix (> Ch ap. 28);
you gave him antibiotics for 2–3 days (> Chap. 47), and by today you expected
him to eat (> Chap. 46) and go home. Instead, your patient lies in bed with a long
face and a distended abdomen, vomiting bile from time to time. And, the family
is asking you what you are asking yourself: what is the problem?
Definitions and Mechanisms
The term ileus as used in this book, and in daily practice, signifies a “paralytic ileus”—the opposite of mechanical ileus, which is a synonym for intestinal
obstruction. In essence, the latter consists of a mechanical stoppage to the normal
transit along the intestine, whereas the former denotes hindered transit because
the intestines are “lazy.”
In previous chapters, you noted that ileus of the small bowel, colon, or both
can be secondary to a variety of intra-abdominal (e.g., acute appendicitis), retroperitoneal (e.g., hematoma), or extra-abdominal (e.g., hypokalemia) causes that
adversely affect normal intestinal motility. Following abdominal operations,
however, ileus is a “normal-physiological” phenomenon—its magnitude directly
proportional to the magnitude of the operation. In general, the more you do
within the abdomen, the more you manipulate, the more prolonged will be the
postoperative ileus.
48
Ileus
Unlike mechanical intestinal obstruction, which involves a segment of the
(small) bowel, postoperative ileus concerns the whole length of the gut, from the
Moshe Schein
Marshfield Clinic Ladysmith Center, 906 College Avenue, Ladysmith, WI 54848, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_48, © Springer-Verlag Berlin Heidelberg 2010
501
502 Moshe Schein · Sai Sajja
stomach to the rectum. As mentioned in > Chap. 46, physiological postoperative ileus
resolves gradually. The small bowel resumes activity almost immediately, followed, a
day or so later, by the stomach; the colon, being the laziest, is the last to start moving.
The magnitude of the postoperative ileus correlates to some extent with
that of the operation performed and the specific underlying condition. Major
dissections, prolonged intestinal displacement and exposure, denuded and inflamed peritoneum, residual intra or retroperitoneal pus or clots are associated
with a prolonged ileus. Thus, for example, after simple appendectomy for nonperforated appendicitis, ileus should be almost nonexistent, whereas after a
laparotomy for a ruptured abdominal aortic aneurysm (> Chap. 41) expect the
ileus to be prolonged. Common postoperative factors that can aggravate ileus are
the administration of opiates and electrolyte imbalance. While the “physiologi-
cal” postoperative ileus is diffuse, ileus due to complications may be local. A
classical example of a local ileus is a postoperative abscess (> Chap. 49) that may
“paralyze” an adjacent segment of bowel. In another example, a localized leak
from an ileo-transverse anastomosis after right hemicolectomy may paralyze the
adjacent duodenum, mimicking a picture of gastric outlet obstruction.
Early Postoperative Mechanical Intestinal Obstruction
You became familiar with small bowel obstruction (SBO) in > Chap. 21. Early
postoperative SBO (EPSBO) is defined as one developing immediately after the
operation or within 4 weeks. Two primary mechanisms are responsible: adhesions
and internal hernia.
Early postlaparotomy adhesions are immature, inflammatory, poor in collagen (thus “soft”), and vascular. Such characteristics indicate that early adhesions may resolve spontaneously, and that surgical lysis may be difficult, traumatic
to involved viscera, and bloody. Postoperative adhesions may be diffuse, involving
the whole length of the small bowel in multiple sites, as is occasionally seen following extensive lysis of adhesions for SBO (> Chap. 21). Localized obstructing adhe-
sions may also develop at the operative site with the bowel adherent, for instance,
to exposed Marlex mesh or raw peritoneal surface. The operation also may create
new potential spaces into which the bowel can herniate to be obstructed, forming
internal hernias. Typical examples are the partially closed pelvic peritoneum after
abdominoperineal resection or the space behind an emerging colostomy. The narrower the opening into the space, the more likely the bowel is to be trapped.
Diagnosis
Failure of your patient to eat, fart, or evacuate his or her bowel within 5 days
after a laparotomy signifies a persistent ileus. The abdomen is usually distended
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