GYNECOLOGIC ONCOLOGY 32, 390-393 (1989)

CASE REPORT

Ogilvie’s Syndrome of Colonic Pseudo-obstruction: A Complication of Radical Hysterectomy with Pelvic and Paraaortic Lymphadenectomy

PRITAM SINGH , MRCOG , *J A. ILANCHERAN, MRCOG,* T. K. TX, FRCS,I- AND S. S. RATNAM, M.D., FRCOG”

*Departments of Obstetrics and Gynaecology and tdurgety, National University of Singapore, National University Hospital, 5 Lower Kent Ridge Road, Singapore 0511

Received August 18, 1987

Ogilvie’s syndrome of colonic pseudo-obstruction has been re- ported in a wide variety of systemic disorders including blunt and surgical trauma but apparently not as a complication of radical hysterectomy with pelvic and paraaortic lymphadenectomy. Its occurrence following extensive paraaortic dissection in this case but no report so far of its occurrence after routine radical hys- terectomy supports the most commonly proposed etiology of dis- turbed splanchnic nerve supply to the colon as a cause. Colonic pseudo-obstruction following radical hysterectomy with pelvic and paraaortlc lymphadenectomy is reported and the etiology, diagnosis, and management are discussed to highlight the condition so that possible associated morbidity/mortality may be avoided. o 1989

Academic Press, Inc.

INTRODUCTION

Pseudo-obstruction of the colon (Ogilvie’s syndrome), a rare but potentially serious condition, describes sudden dilatation of the cecum and colon in the absence of a mechanical obstructive lesion. It may present as a difficult diagnostic and therapeutic problem and result in potentially fatal complications of cecal perforation, bowel ischemia, or colonic perforation. It occurs in a wide variety of extraabdominal conditions but has received insufficient recognition in gynecologic oncology and a literature search revealed no report of its occurence following radical hys- terectomy with retroperitoneal lymphadenectomy. Pseudo- obstruction of the colon occurring as a complication of radical hysterectomy with pelvic and paraaortic lymph- adenectomy is described in this report and the etiology, diagnosis, and management are discussed to facilitate early diagnosis and engender appropriate therapy so that serious and potentially fatal complications may be avoided.

’ To whom all correspondence should be addressed.

CASE REPORT

A 48-year-old Chinese woman was diagnosed on 12 March 1986 to have a 6-cm-diameter cervical cancer in clinical stage IB (FIGO) with histology of large-cell non- keratinizing type. A preoperative workup including an intravenous urogram, a chest radiograph, and hematologic and biochemical investigations of renal and hepatic func- tion were all within normal range. A computerized tom- ographic (CT) scan of the abdomen and pelvis revealed no enlarged pelvic or paraaortic lymph nodes or other areas involved by metastatic deposits. She elected for surgical treatment and on 7 April 1986 a radical hyster- ectomy (Okabayashi type) was performed which included a thorough pelvic and in addition, a paraaortic lymph- adenectomy. The paraaortic lymphadenectomy removed all lymphatic and areolar tissue from the anterior aspect of the inferior vena cava and from the anterior and lateral aspects of the aorta from the inferior bifurcation of these vessels to the origin of the renal vessels. Only two of the most proximal lymph nodes on the lateral aspect of the right external iliac artery were clinically enlarged to 1 cm but no suspect paraaortic lymph nodes were noted. The procedure was uncomplicated and routine closed suction drainage with drainage tubes leading from the paravesical and pararectal spaces through the abdominal wall on either side was used and a suprapubic catheter inserted. Histopathologic examination confirmed a large- cell nonkeratinizing squamous carcinoma of the cervix and a total of 57 lymph nodes all of which were negative for metastases.

She started to take oral fluids from the 3rd postoperative day following discontinuation of nasogastric aspiration but progressive abdominal distension set in despite good (tingling-type) bowel sounds. Oral fluids were then stopped

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CASE REPORT 391

and a regime of nasogastric aspiration and intravenous fluid therapy was instituted. Serial erect (Fig. 1) and supine (Fig. 2) abdominal radiographs revealed absent air-fluid levels in the small bowel; dilated large bowel shadows were seen though without air-fluid levels and mechanical obstruction was thought to be unlikely as she obtained good though temporary relief either by insertion of a large-bore rectal tube or simple enemas. An intra- venous urogram on the 9th postoperative day was reported to show no urinary tract obstruction and she remained stable despite a persistent severe generalized abdominal distension but with little relief from the small volumes aspirated through the nasogastric tube. From the 13th postoperative day she developed a temperature reaching 39.5”C, which persisted despite parenteral broad-spectrum antibiotic therapy. The fever was associated with a marked leukocytosis of 15,600 x lo-‘/liter from a previous value of 5800 x lo-‘/liter and an increase in the abdominal girth of 15 cm over 3 days. An ultrasonographic exam- ination of the abdomen suggested the presence of a small abdominal wall abscess with a small volume of ascites; because of a persisting fever increasing leukocytosis and

progressive abdominal distension with unresolving large bowel ileus an exploratory laparotomy was performed on the 16th postoperative day to exclude bowel ischemia or impending bowel perforation.

At laparotomy, a gross and severe gaseous dilatation of the colon was noted from the cecum to the rectum but no subphrenic, paracolic, or pararectal abscess was found on thorough exploration. The small bowel was collapsed and normal in its entire length. No portion of the colon revealed impending perforation and in no part did it appear ischemic or nonviable. A large-bore rectal tube was introduced per rectum and guided into the mid- portion of the decending colon, the colon was manually decompressed and the rectal tube left in situ. The ab- dominal distension gradually diminished over the next 7 days and she could tolerate oral fluids from the 4th day and progressed within a week to taking a normal diet. She was discharged 2 weeks following the reexploration with the suprapubic catheter in situ after full recovery from the abdominal distension. The suprapubic catheter was left in situ to enable self-measurement of the residual urine volume twice daily at home. At follow-up, 4 weeks

FIG. 1. An erect radiograph in colonic pseudo-obstruction showing gaseous distension of the colon most severely affecting the descending portion with very few air-fluid levels. The tip of a nasogastric tube is seen overlying the last left rib as well as multiple hemostatic metal clips.

FIG. 2. A supine radiograph showing the colon to be severely distended over its entire length from the cecum to a characteristic sharp “cut-off-point” at the rectosigmoid junction. A pelvic drainage tube is seen in the left pelvis.

392 SINGH ET AL.

later the suprapubic catheter was removed when residual urine volumes were 80 ml. At subsequent follow-up visits, she needed laxative prescriptions for 4 months to aid evacuation but by 6 months she opened her bowels every other day without medication and has remained well and free of tumor recurrence until 12/86.

DISCUSSION

Pseudo-obstruction of the colon was first described by Ogilvie in 1948 [l] when he reported two cases with clinical evidence of colonic obstruction suggesting me- chanical obstructive lesions in whom abdominal explo- ration revealed extensive malignant disease involving the coeliac axis and semilunar ganglion but no lesions causing mechanical colonic obstruction. He postulated the etiology as being due to relative symphathetic denervation from tumor infiltration of the splanchnic nerves supplying the colon. Subsequent reports of “Ogilvie’s syndrome” de- scribed its occurrence in a wide variety of major ex- traabdominal systemic disturbances including sepsis, res- piratory or cardiac failure, pancreatitis, blunt or surgical trauma [2], and mechanical ventilation [3]. Caesarean section is reputedly the commonest cause of colonic pseudo-obstruction in women [4] followed by urologic surgery, while in men the latter is the commonest cause [5]. Though hysterectomy is listed as a cause of colonic pseudo-obstruction [3] no instance of its occurrence fol- lowing radical hysterectomy could be found in the literature surveyed and the condition seems not be commonly en- countered in gynecologic oncology writings.

Various etiologic mechanisms have been postulated for the atonic colonic musculature in pseudo-obstruction but most center around a disturbance to the autonomic in- nervation of the colon causing a parasymphathetic de- ficiency [6] or a symphathetic-parasymphathetic neu- rostimulatory imbalance [7]. Schuffler et al. [8] reported it as a paraneoplastic manifestation when widespread myenteric plexus degeneration was found in association with an oat cell carcinoma of the lung and it has also been reported as a sequel of measles encephalitis [9] with reduction of both submucosal and myenteric plexuses, decreased ganglion cells, and Schwann cell proliferation; all of these features support an intestinal neuropathy as a cause of colonic pseudo-obstruction. In our case, the extensive retroperitoneal dissection of the paraaortic lymphatic and areolar tissues and inevitable disturbance to the splanchnic nerve supply to the colon seems to best explain the pseudo-obstruction. It is interesting to speculate that routine radical hysterectomy with pelvic lymphadenectomy has not featured in the literature as a cause of Ogilvie’s syndrome because the routine procedure results only in interruption of the sacral 2, 3, and 4 parasymphatetic supply during dissection in the paravesical

and pararectal fossae to enable resection of the cardinal ligament, leading to the commonly observed symptoms of bladder and rectal denervation. An important recent observation by Hall et al. [IO] reported colonic pseudo- obstruction following extraperitoneal lymph node dis- section without radical hysterectomy for surgical staging of cervical cancer which lends further support to the retroperitoneal paraaortic dissection interrupting or causing disturbance of the splanchnic nerve supply to the colon as a likely cause of the syndrome. A report of a large series of paraaortic lymphadenectomies in gynecologic cancer by Bellinson et al. [ll], however, reported no instance of colonic pseudo-obstruction. The reasons for this observation and for the syndrome not being reported more frequently as one would be led to expect in paraaortic dissections we feel may be due to variations in technique, thoroughness of dissection, and anatomical variations in the route of splanchnic nerve supply, resulting in varying extent of interruption of the colonic autonomic innervation.

Pseudo-obstruction of the colon presents with sudden massive abdominal distension, absent or crampy abdominal pain, absent or poor bowel sounds, and other symptoms suggestive of obstruction of the colon which are quite distinct from the common postoperative paralytic ileus. The patient may appear relatively well if the cause is not some major extraabdominal systemic disturbance or catastrophe but due only to a specific disturbance of the splanchnic nerve supply. In an uncomplicated situation abdominal tenderness is often mild or absent and not proportional to the degree of abdominal distension as in our case. Severe abdominal pain, increasing leukocytosis, or signs of peritoneal irritation may all herald impending or actual cecal perforation and thus precipitate perfor- mance of an exploratory laparotomy to exclude these possibilities as in this case whereas peritonitis may be a sign of bowel ischemia or colonic perforation. Plain ab- dominal radiographs reveal enlargement of the cecum and right, transverse, and descending colon but multiple air-fluid levels so characteristic of mechanical obstruction are often absent in pseudo-obstruction. Obstructive lesions may be excluded by sigmoidoscopy or barium enema examinations but more recently, colonoscopy has in- creasingly superseded these to both exclude obstruction and decompress the bowel [12]. The salient features of radiographic examinations are (1) massive gaseous dis- tension of the cecum and variable distances of the distal colon to a cut-off-point; (2) lack of a fluid-filled colon; (3) normal endoscopic examination; and (4) barium enema examination which rules out mechanical obstruction and volvulus and mesenteric vascular ischemia 1131. Plain abdominal radiographs are among the most useful tests to help decide on appropriate management in the absence of clinical signs of bowel ischemia or impending perfo- ration. The results of Lowman’s and Davis’s study 1141

CASE REPORT 393

of radiographic transverse cecal diameters implied im- pending cecal perforation when the measurement exceeded 9 cm and is taken as an indication for colonic de- compression using rectal tubes or colonoscopy to release gas and fluid by suction or high endoscopic placement of large-caliber drainage tubes; both measures have been highly successful [12]. When cecal diameter reaches or exceeds 12 cm or colonoscopic decompression is un- successful, operative intervention with a tube cecostomy or loop colostomy have been procedures most often used successfully, though with an associated 15% mortality. However, with supervening bowel ischemia or cecal or colonic perforation necessitating coeliotomy and appro- priate bowel resection, the mortality rate rises to about 50% [15].

The paraaortic nodes are now well recognized as sites of lymphatic spread from cancer of the uterus (cervix and corpus) and the ovaries [16]. Retroperitoneal explo- ration with paraaortic node dissection is increasingly uti- lized for an accurate assessment of disease extent during surgical treatment of these malignancies in contemporary gynecologic oncologic practice. With more widespread adoption of these staging techniques, colonic pseudo- obstruction may be expected to occur more often than in the past. This report highlights the condition to facilitate early diagnosis and reviews its current management so that appropriate early intervention can help to avoid the previously associated high mortality.

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