Colonic Obstruction Postoperative colonic obstruction following surgery for most gynecologic conditions is exceedingly rare. It is associated with a pelvic malignancy, which in most cases was known at the time of the initial operation. Advanced ovarian carcinoma is the most common cause of colonic obstruction in postoperative gynecologic surgery patients, and it is caused by extrinsic impingement on the colon by the pelvic malignancy. Intrinsic colonic lesions may be undetected, especially in a patient with some other benign gynecologic condition. When colonic obstruction is manifested by abdominal distention and abdominal radiography reveals a dilated colon and enlarging cecum, further evaluation of the large bowel is required by barium enema or colonoscopy. Dilation of the cecum to more than 10 to 12 cm in diameter as viewed by abdominal radiography requires immediate evaluation and surgical decompression by performing colectomy or colostomy. Surgery should be performed as soon as the obstruction is documented. Conservative management of colonic obstruction is not appropriate because the complication of colonic perforation has an exceedingly high mortality rate. In patients who are too ill to undergo surgery, the interventional radiologist may be able to place a cecostomy tube or the gastroenterologist may place a colonic stent (124).
Diarrhea Episodes of diarrhea often occur following abdominal and pelvic surgery as the gastrointestinal tract returns to its normal function and motility. Prolonged and multiple episodes may represent a pathologic process such as impending small bowel obstruction, colonic obstruction, or pseudomembranous colitis. Excessive amounts of diarrhea should be evaluated by abdominal radiography and stool samples tested for the presence of ova and parasites, bacterial culture, and Clostridium difficile toxin. Proctoscopy and colonoscopy may be advisable in severe cases. Evidence of intestinal obstruction should be managed as outlined previously. Infectious causes of diarrhea should be managed with the appropriate antibiotics and ﬂuid and electrolyte replacement. C. difficile–associated pseudomembranous colitis may result from exposure to any antibiotic. Discontinuation of these antibiotics (unless they are needed to treat another severe infection) is advisable, along with the institution of appropriate therapy. Oral metronidazole is a suitable agent for instituting therapy and is less expensive than vancomycin. Therapy should be continued until the diarrhea abates, and several weeks of oral therapy may be required to obtain complete resolution of the pseudomembranous colitis.
Fistula Gastrointestinal fistulas are relatively rare following gynecologic surgery. They are most often associated with malignancy, prior radiation therapy, intestinal resection with anastomosis, or surgical injury to the large or small bowel that was improperly repaired or unrecognized. Signs and symptoms of gastrointestinal fistula are often similar to those of small bowel obstruction or ileus, except that fever is usually a more prominent component of the patient’s symptoms. When fever is associated with gastrointestinal dysfunction postoperatively, evaluation should include early assessment of the gastrointestinal tract to confirm its continuity. When fistula is suspected, the use of water-soluble gastrointestinal contrast material is advised to avoid the complication of barium peritonitis. Evaluation with abdominal pelvic CT scan may assist in identification of a fistula and associated abscess. Recognition of an intraperitoneal gastrointestinal leak or fistula formation usually requires immediate surgery, unless the fistula drained spontaneously through the abdominal wall or vaginal cuff.