Incidence And Risk Factors Of Postoperative Ileus After Hysterectomy

1 Background and objectives:Postoperative ileus(POI)is defined as gastrointestinal dysfunction after abdominal and other types of surgery.It is characterized as nausea,vomiting,abdominal distension,lack of bowel sound,accumulation of gas and fluids in the bowel,and delayed passage of flatus and stool.POI can cause undesirable consequences,including patient discomfort,decreased patient satisfaction,delayed mobilization,increased risk of postoperative complications,and increased length of hospital stay.Due to the variation of the definition used in different study,incidence of POI was estimated between 3%and 32%after abdominal surgery.The etiology of POI is multifactorial.Factors that contribute to the development of POI include surgical stimulation,inflammation,opiods,and neural reflex.A multimodal perioperative management protocol or so-called Enhanced Recovery After Surgery(ERAS)was well recognized for its effect on accelerating the recovery of gastrointestinal tract.Several RCTs have demonstrated ERAS was effective in shortening the length of hospital stay after abdominal surgery.However,POI remain a common complication after abdominal and other type of surgery.Indentifying patients at increased risk of POI plays an important role in the monitoring,diagnosing,and treating of the development of POI.Hysterectomy is one of the most common gynecologic surgery around the world.Incidence and risk factors of POI after hysterectomy for benign indications have not been reported before.This retrospective study aims to review the medical charts of hysterectomy patients,identifying the incidence and risk factors of POI after hysterectomy.2 Objects and methods:2.1 Objects:Patients who underwent hysterectomy for benign gynecologic diseases in Southern Hospital from January 2013 to December 2017 were included in this study.2.2 Inclusion and exclusion criteria:Inclusion criteria:(1)hysterectomy was indicated for benign gynecologic diseases;(2)patient aged?18;(3)elective surgery;(4)medical record was complete.Exclusion criteria:(1)hysterectomy was indicated for malignant condition,pre-cancerous diseases,or obstetric condition;(3)cancer or pre-cancerous diseases was confirmed through pathology test after surgery;(4)emergent surgery;(5)medical record was incomplete.2.3 Diagnosis criteria of POI:POI was specifically defined as:delayed passage of flatus(over 2 days after surgery)with symptoms of nausea/vomiting or abdominal distension.2.4 Data collection:Data were extracted from the medical record and anesthesia record of the included patients.Perioperative variables were classified as clinical variables,surgical variables,and outcome variables.Clinical variables include:age,BMI,ASA,parity,gravidity,history of surgical abortion,dysmenorrhea,menopause,tubal sterilization,history of abdominal sugery(cesarean delivery,laparotomy,laparoscopic surgery),and comorbidity(diabetes,hypertension,cardiovascular diseases,respiratory diseases,chronic renal dysfunction,hepatitis B,cancer,pelvic inflammation,and anemia).Surgical variables include:indications(fibroids,endometriosis/adenomyosis,prolapse,menstrual disorder),surgical route(abdominal,laparoscopic,vaginal),anesthesia type(general anesthesia,spinal anesthesia,combined epidural anesthesia),mechanical ventilation,range of hysterectomy(supracervical hysterectomy,total hysterectomy),uterine size,concurrent surgery(adhesiolysis,salpingectomy,oophorectomy),transfusion,duration of surgery,estimated blood loss,and patient-controlled analgesia.Outcome variables include:POI,postoperative complications(diarrhea,fever,infection,pneumonia,thromboembolic event,wound complication,and urinary distention),and length of hospital stay.2.5 Statistical analysis:Statistical analysis was performed using SPSS 20.0 software.Continuous data were expressed as meanss±SD.Categorical data were expressed as frequency and percentage.Categorical data were compared using chi-square test.Continuous data were compared using students't test.Rank data were compared using rank sum test.Variables with a p-value of<0.1 were entered into a multivariate logistic regression model to identify independent risk factors of POI.A p-value of<0.05 was considered statistical significant.3 Results:A total of 1017 patients underwent hysterectomy in Southern Hospital from January 2013 to December 2017 were included in this study.Among which,432 patients(42.5%)underwent abdominal hysterectomy,523 patients(51.4%)underwent laparoscopic hysterectomy,62 patients(6.1%)underwent vaginal hysterectomy.POI was developed in 94 patients(9.2%).Incidence of POI did not differed significantly among three different routes of hysterectomy.Patients who developed POI had higher risk of postoperative complications(39.4%vs 29.1%,p=0.04),and increased length of hospital stay(9.15±3.20 days vs 8.42±2.62 days,p=0.013).Independent risk factors identified by multivariate logistic regression include:operative duration(OR=1.005,95%CI 1.000-1.010,P=0.047),adhesiolysis(OR=1.852,95%CI 1.166-2.941,p=0.047),dysmenorrhea(OR=1.745,95%CI 1.110-2.744,p=0.016),hepatitis B(OR=3.529,95%CI 1.463-8.510,p=0.005),and anesthesia type(general anesthesia vs combined epidural anesthesia)(OR=2.656,95%CI 1.524-4.626,p=0.001).4 Conclusion:Incidence of POI after hysterectomy for benign indications was approximately 9.2%.Risk of hysterectomy did not differed significantly among three different routes of hysterectomy.POI increased length of hospital stay and risk of postoperative complications.Independent risk factors of POI identified by multivariate logistic regression include operative duration,dysmenorrhea,hepatitis B,adhesiolysis and anesthesia type(general anesthesia vs combined epidural anesthesia).