Distal small bowel motility and lipid absorption in patients following abdominal aortic aneurysm repair surgery

Abstract

Aim: To investigate distal small bowel motility and lipid absorption in patients following elective abdominal aortic aneurysm (AAA) repair surgery.

Methods: Nine patients (aged 35-78 years; body mass index (BMI) range: 23-36 kg/m(2)) post-surgery for AAA repair, and seven healthy control subjects (20-50 years; BMI range: 21-29 kg/m(2)) were studied. Continuous distal small bowel manometry was performed for up to 72 h, during periods of fasting and enteral feeding (Nutrison). Recordings were analyzed for the frequency, origin, length of migration, and direction of small intestinal burst activity. Lipid absorption was assessed on the first day and the third day post surgery in a subset of patients using the (13)C-triolein-breath test, and compared with healthy controls. Subjects received a 20-min intraduodenal infusion of 50 mL liquid feed mixed with 200 microL (13)C-triolein. End-expiratory breath samples were collected for 6 h and analyzed for (13)CO(2) concentration.

Results: The frequency of burst activity in the proximal and distal small intestine was higher in patients than in healthy subjects, under both fasting and fed conditions (P<0.005). In patients there was a higher proportion of abnormally propagated bursts (71% abnormal), which began to normalize by d 3 (25% abnormal) post-surgery. Lipid absorption data was available for seven patients on d 1 and four patients on d 3 post surgery. In patients, absorption on d 1 post-surgery was half that of healthy control subjects (AUC (13)CO(2) 1323+/-244 vs 2646+/-365; P<0.05, respectively), and was reduced to the one-fifth that of healthy controls by d 3 (AUC (13)CO(2) 470+/-832 vs 2646+/-365; P<0.05, respectively).

Conclusion: Both proximal and distal small intestinal motor activity are transiently disrupted in critically ill patients immediately after major surgery, with abnormal motility patterns extending as far as the ileum. These motor disturbances may contribute to impaired absorption of enteral nutrition, especially when intraluminal processing is necessary for efficient digestion.

Figure 1

Schematic representation of manometry recording periods in two patients: ventilated and fasting (gray), non-ventilated and fasting (white), non-ventilated and feeding (black); and analysis periods: early ventilation (EV) (1-5 h), early post-operative (EP) (20-24 h), early feeding (EF) (29-33 h), late feeding (LF) (53-57 h) and late post-operative (LP) (68-72 h).

Figure 2

Bursts recorded during fasting (early ventilation (EV) (1-5 h), early post-operative (EP) (20-24 h) and late post-operative (LP) (68-72 h)) and enteral feeding, in patients (gray shading) and healthy controls (black shading) (n = 7). Data are mean±SE. P < 0.0001 vs healthy fasting, P < 0.0001 vs healthy fed. early ventilation (n = 9), early post-operative (n = 7), enteral feeding (n = 8), late post-operative (n = 9).

Figure 3

Normal burst activity (% of total burst activity) recorded during fasting (early ventilation (EV) (1-5 h), early post-operative (EP) (20-24 h) and late post-operative (LP) (68-72 h)) and enteral feeding in patients (gray shading) and healthy control subjects (black shading) (n = 7). Data are mean±SE. P < 0.01 vs late post-operative. early ventilation (n = 9), early post-operative (n = 7), enteral feeding (n = 8), late post-operative (n = 9).

Figure 4

Sample patient small intestinal manometric tracing during fasting. A: d 1 showing characteristic disordered burst activity with simultaneous onset and retrograde propagation; B: d 3 bursting activity is less frequent and predominantly antegrade.

Figure 5

Area under the curve for percentage dose recovery of ¹³CO2 until 6 h after the start of the intraduodenal infusion on d 1 (n = 7) and d 3 (n = 4) post surgery in AAA repair patients and in healthy subjects (n = 8). P < 0.05 vs healthy. Data are mean±SE.