Abstract

Postoperative ileus is considered an undesirable response to major abdominal surgery that leads to discomfort, complications, morbidity, and the prolongation of hospital stays. Although thoracic epidural analgesia has been introduced to prevent and/or reduce postoperative ileus, it is rarely used as a way to treat postoperative ileus. A 65-year-old man developed paralytic ileus after undergoing a colectomy. Despite conservative and surgical management, postoperative morbidity persisted. A continuous infusion of 0.2% levobupivacaine at a rate of 4 mL/hour was administered for 4 days via a thoracic epidural catheter that had been percutaneously tunneled into the T11–T12 epidural space. With this treatment, daily drainage from a nasogastric tube was gradually decreased and flatus was noted. A week later, the patient could start receiving a liquid diet. Therefore, thoracic epidural analgesia can be used to treat or alleviate paralytic ileus.

Keywords

analgesia, epidural; postoperative complications; anesthetics, local;

1. Introduction

Postoperative ileus (POI) is considered an undesirable response to major abdominal surgery that leads to discomfort, complications, morbidity, and prolonged hospital stays.¹ Catecholamines and cytokines are released in response to the stress of surgery and the use of certain antiemetic medications, opioid analgesics, and inhaled anesthetics are factors that contribute to the development of POI.²

By applying thoracic epidural analgesia (TEA), sympathetic blockers cause decreased splanchnic hypoperfusion3, 4 and increased peristalsis due to unbalanced parasympathetic stimulation. TEA has been used to prevent and/or reduce postoperative ileus. However, the use of TEA to manage ileus has seldom been reported.⁵ Here, we presents a case of paralytic ileus that was successfully treated using TEA.

2. Case report

A 65-year-old man underwent a colectomy at our hospital due to tubular adenoma of the transverse colon. Two days after discharge and 10 days after the 6-hour operation, he visited our emergency department complaining of persistent distention of the abdomen. Plain abdominal X-ray films showed a nonspecific increase in bowel gas. Under the tentative diagnosis of adhesion ileus, he was again admitted to our hospital. Conservative treatment comprising of nasogastric tube decompression and parenteral nutrition support was administered. Ten mg intravenous metoclopramide was administered every 8 hours for 22 days, then discontinued for 27 days before intervention with TEA. A single intravenous administration of 0.5 mg neostigmine was delivered in an attempt to facilitate a bowel movement 16 days before the application of TEA. Small bowel series with barium indicated partial obstruction of the fourth portion of the duodenum. Three weeks after admission, the patient underwent enterolysis and resection of the adhesive intestine due to the failure of previous treatments. The operation lasted for 6.5 hours, and the patient's hemodynamic parameters were stable. The patient lost about 600 mL of blood, and he was transfused with 500 mL of packed red blood cells. To control postoperative pain, patient-controlled analgesia (morphine) was available for 3 days. The daily dosages of morphine were 24 mg on day 1, 10 mg on day 2, and 4 mg on day 3. The visual analogue scale determined pain scores (range: 0–100) during rest/movement of 40/80 on day 1, 20/50 on day 2, and 10/40 on day 3, respectively. After the forth postoperative day (24 days before TEA intervention), the patient did not complain of wound pain or receive any analgesics or medication that would induce ileus. Although his magnesium and potassium levels were within normal ranges, he was still troubled by the same symptoms for a month after the operation until we were consulted.

Under fluoroscopic guidance with contrast enhancement, the T11–T12 epidural space was identified and by an epidural catheter about 5 cm from the skin via the paramedian translaminar approach (Fig. 1, Fig. 2, Fig. 3). The tip of the epidural catheter was anchored at the T11 level (Fig. 2) after implantation of the epidural catheter via percutaneously tunneling into the epidural space at the T11–T12 level. Initially, 0.2% levobupivacaine was continuously infused at a rate of 5 mL/hour. We decreased the infusion rate to 3 mL/hour for 1 day because the patient complained of numbness of the lower limbs and urinary incontinence. The following day, the infusion rate was increased to 4 mL/hour to accelerate bowel movement, and the side effects did not appear again. We encouraged the patient to use the patient-controlled bolus of 4 mL of 0.2% levobupivacaine each time he was lying in bed. He used the extra bolus eight times per day (on average) without developing motor weakness. TEA treatment was continued for 4 days.

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Fig. 1. Anterior-posterior (AP) view of a fluoroscopic image showing that the epidural catheter was introduced into the T11–T12 interspinal epidural space using the paramedian translaminar approach and coiled around the T11 level.

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Fig. 2. After placement of the catheter, a contrast medium was injected into the epidural space to confirm that the tip of epidural catheter was at the T11 level.

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Fig. 3. Epidurogram (lateral view) showing that the contrast medium extended up to the T10 epidural space.

During treatment, daily drainage from the nasogastric tube was dramatically decreased and flatus was noted (Fig. 4). To our satisfaction, he started taking a liquid diet a week later. Finally, the patient was discharged 15 days after the termination of TEA. He is in good health, and the ileus had not recurred by the 16-month follow-up examination.

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Fig. 4. Diagram of the amount of nasogastric drainage versus oral intake after the administration of thoracic epidural analgesia (TEA). The dotted line indicates the amount of nasogastric drainage, which dramatically decreased after the administration of TEA. The solid line indicates the amount of the oral liquid intake, which gradually increased after commencing oral intake. The gray box represents the period of the TEA treatment, which lasted for 4 days (February 23–27).

3. Discussion

TEA was first found to be useful for the treatment of postoperative adynamic ileus in the 1970s.⁶ Local anesthetics were found to shorten the duration of postoperative ileus after colonic surgery and hysterectomy.7, 8 Compared with epidural local anesthetics, morphine yields more satisfactory pain relief and is not associated with motor block, signs of sympathetic block, or loss of sensitivity to temperature, touch, or pin-prick.⁹ Nevertheless, morphine has other side effects such as pruritus, nausea and vomiting, respiratory depression, and gastrointestinal dysfunction.¹⁰ Thus, local epidural anesthetics and intravenous opioid-sparing nonsteroidal anti-inflammatory drugs are now multimodally combined for use as postoperative epidural analgesia. If local anesthetics and opioids are used as epidural analgesia, buprenorphine is preferred due to its minimal effects on the gastrointestinal smooth muscle.²

TEA offers additional nonanalgesic effects due to sympathetic blocking, and the local anesthetic is reabsorbed from the epidural space.¹¹ TEA could affect the stress response and cardiac, pulmonary, and gastrointestinal functions. Administering TEA at a high level (T1–T5) reduces the chronotropic and inotropic effects of beta-adrenergic receptor stimulation. TEA also increases the repolarization and refractoriness of cardiac cycles, resulting in a lower heart rate and the decreased possibility of dysrhythmias and thrombotic complications during cardiac¹² and pulmonary surgeries.¹³

TEA's effects on pulmonary functions include the blocking of the intercostal nerves, thereby reducing rib cage movement. On the other hand, TEA also blocks reflex inhibition of the phrenic nerve, thereby improving functional residual capacity and tidal volume. There are also minimal changes in hypoxic pulmonary vasoconstriction,¹⁴ arterial oxygenation, and the shunt fraction during one-lung ventilation.¹⁵ TEA inhibits a major part of the endocrine metabolic response, leading to improved protein economy without significantly affecting inflammatory or immunologic responses.¹⁶ TEA in combination with local anesthetics blunts the surgical stress response.¹⁷ However, this has not been observed when used with opioid analgesics, either systemically or via TEA.¹⁸

The gastrointestinal effects of TEA include increased gastrointestinal blood flow, superior pain control, reduction of opioid requirements,¹⁹ systemic absorption of local anesthetics,20, 21 and the attenuation of the occurrence of POI.¹⁷ Innervating most of the digestive tract, the great and small splanchnic nerves, which are formed by the branches of the sixth to the eleventh ganglia of the thoracic cord, laterally run across the T11–T12 vertebral body and primarily end at the celiac ganglia, which are a part of the sympathetic subdivision of the autonomic nervous system and are located in front of the T12–L1 vertebral body.²² We chose T11–T12 interspinous space when approaching the spinal origin of the celiac ganglia because advancing a catheter too far into the epidural space could cause the migration of the catheter into the vessels or the coiling of the catheter²³ in the lower interspinal space; by using such an approach, hypotension or bradycardia caused by a high level of TEA from the higher interspinal space can be avoided. The epidurogram (Fig. 3) shows that the contrast medium was extended up to least the T10 epidural space, which was sufficient to block the origin of the celiac ganglia.

Spinal sensory neurons and calcitonin gene-related peptide (CGRP) partly mediate postoperative gastric ileus. CGRP may be released from spinal sensory neuron terminals in the celiac and superior mesenteric ganglia as a part of the extraspinal intestinogastric inhibitory reflex that is activated by abdominal surgery.²⁴ Celiac ganglionectomy significantly improves delayed gastrointestinal transit in rats.²⁵

Theoretically, celiac ganglia block could also alert the autonomic nervous system of the intestines to increase bowel movement. Because celiac ganglia block is more invasive and technically demanding, TEA would be an easier way to achieve the same effects.

Strategies for preventing POI include reduced narcotics usage,²⁶ nasogastric tube removal,²⁷ early ambulation and oral intake, use of laparoscopy, restricting intravenous fluids, and the use of prokinetics and TEA.² Rarely has TEA been used to treat POI. Only one study has reported the use of the same method described here to treat POI.⁵ Here, we presented a case of paralytic ileus that was successfully treated using TEA. Therefore, TEA can be used to treatment and alleviate paralytic ileus.