~ Post Surgery Update ~ NJ Feeding Tube / E-Coli Bacterial Infection

Consultation with Nutrition

Clinical Notes
Consults – Outpatient, APRN, C.N.P. at 11/7/2025  5:47 PM
CHIEF COMPLAINT / REASON FOR VISIT
Malnutrition consultation

HISTORY OF PRESENT ILLNESS

-Ms. Nichole Anderson is a 44 y.o. female whose medical history is nutritonally notable for chronic constipation, colonic dysmotility, pelvic floor dysfunction.  
-She underwent robotic assisted laparoscopic hysterectomy with excision of endometriosis and laparoscopic ureterolysis on 10/30/2025.
-Medical history also includes Wolff-Parkinson-White syndrome, tachycardia, occipital neuralgia, migraine headaches, history of iron-deficiency anemia, major depressive disorder, and endometriosis..

Nichole Anderson is a 44 year old female who presents for a malnutrition consultation. She is accompanied by her son, Caden.

She has a long-standing history of gastrointestinal issues, which have worsened since 2024. She experiences frequent, fatty, oily, and loose stools that are described as ‘disgusting’ and ‘floaty’. Over time, her bowel movements became less frequent, requiring Miralax to have a bowel movement every few days, yet her stools remain loose and oily.

In 2024, she noticed a mass on her right side, initially thought to be related to endometriosis or adhesions from previous ovarian surgery, but imaging suggested stool accumulation. During a recent surgery, her colon appeared empty except for the ascending colon, which was full. Colonoscopy preps have become ineffective, and she experiences pencil-thin, loose stools. Eating leads to nausea, vomiting, hiccups, and burps, and medications to move stool have become less effective.

In July 2025, she was unable to complete a 100-gram fat diet test due to inability to produce a bowel movement, leading to her first ED visit and a five-day hospitalization for attempted bowel clearance, which was unsuccessful. She experiences significant weight loss, which fluctuates with her bowel movements. She has difficulty swallowing, choking, and aspirating on both solids and liquids. She is currently on a full liquid diet, primarily consuming Kate Farms shakes, which she tolerates better than other nutritional supplements.

She moved from Portland, Oregon, to Rochester for better access to medical care due to long wait times in Portland. She has not been able to work since her health declined, previously working as a school LPN nurse. She reports significant financial hardship due to her inability to work and the cost of nutritional supplements.

No smoking, alcohol, or drug use. She experiences cold intolerance, feeling cold even when others feel warm. She has a history of low vitamin D and vitamin C levels, with previous supplementation for vitamin D. She reports significant muscle loss, particularly in her upper body, and decreased physical activity due to weakness and dizziness.

Weight history:  

Wt Readings from Last 6 Encounters:
11/07/25	48.6 kg = 107 lbs
10/31/25	54.1 kg (Post Procedure)
10/13/25	49 kg
10/07/25	49.1 kg
10/07/25	48.9 kg
09/09/25	54.3 kg

Body mass index is 18.4 kg/m².

PHYSICAL EXAMINATION

General: Alert, Oriented x 4, NAD
Musculoskeletal: Strength 5/5 bilateral upper and lower extremity gross muscle groups and hand grips. No overt muscle wasting appreciated. 
Cardiac: S1S2, regular rhythm, no extra sounds
Respiratory: Lungs CTA bilaterally, normal respiratory effort and excursion
Abdomen: soft, nontender to palpation, normoactive bowel sounds in four quadrants

Extremities: 
–3/2025:  Gastric emptying study was normal.
–8/21/25:  EGD examined esophagus was normal.  They did note presence of rings during diagnostic dilation.  Examined stomach was normal and examined duodenum was normal.
–9/4/25:  CT abdomen pelvis noted some mild wall thickening of the colon as well as large colonic stool burden.
–10/14/25:  nuclear medicine study revealed slight decrease in gastric accommodation.
–10/20/25:  Colonic transit study noted slow colonic transit.

Bio Impedance Body Composition Testing: 
Weight:  40.6 kg 
Skeletal Muscle Mass:  19.2 kg 
Dry Lean Mass:  9.8 kg 
Body Fat Mass:  11.7 kg 
Percent Body Fat:  24.1%
Visceral Fat Mass:  61.4 centimeters squared 
Water Analysis:  0.399 (Normal: 0.360-0.390) 
Whole Body Phase Angle:  3.6 degrees  
Segmental Lean Analysis:
Right Arm:  1.64 kg
Left Arm:  1.56 kg
Trunk:  15.8 kg
Right Leg:  5.48 kg
Left Leg:  5.44 kg

ASSESSMENT / PLAN  
#1 Malnutrition Severe Protein-Calorie (HCC)
#2 Dysphagia

Assessment & Plan
Severe protein-calorie malnutrition with weight loss
Severe malnutrition due to inadequate oral intake in the setting of constipation and overflow diarrhea, pelvic floor dysfunction with resultant early satiety, nausea and vomiting. We had a lengthy discussion today. Considered tube feeding to address deficits and promote weight gain. Explained risks and benefits of tube feeding. Goal is to ultimately transition back to oral intake, once she has rehabilitated nutritionally.

ROBOTIC-ASSISTED EXCISION ENDOMETRIOSIS;
ROBOTIC-ASSISTED LAPAROSCOPIC URETEROLYSIS Bilateral

Pre-op Diagnosis
Adenomyosis of the uterus
Pain, pelvic, female, chronic

Summary

In simple terms, this surgery was a robotic-assisted hysterectomy to help relieve long-term pelvic pain caused by adenomyosis — a condition where tissue that normally lines the uterus grows into the muscle wall.
During the operation, the surgeon took a careful look around and found that most of the abdomen and pelvic area looked healthy, with no major scarring or disease. The uterus appeared mostly normal, though final lab results (pathology) will confirm whether adenomyosis was present.
The right ovary and both fallopian tubes had already been removed from a prior surgery, while the left ovary looked healthy except for two small cysts that were drained. The surgeon also removed a few tiny spots that looked like possible endometriosis — tissue similar to what lines the uterus but growing outside it — as well as a small thin area in the pelvic tissue called an Allen-Master window.
Everything went smoothly from start to finish. There were no complications, and a final check of the bladder and surrounding organs showed everything was intact and working well. The patient woke up safely and was moved to recovery in good condition.

Details from Surgeon👨🏻‍⚕️

Findings:

Normal-appearing upper abdominal survey with no disease noted. Bilaterally colic gutters were free of disease. Normal-appearing appendix. No significant intra-abdominal adhesive disease from the bowel to sidewalls, anterior abdominal wall, or pelvic structures was observed. There was global increased stool burden throughout small and large bowel except the rectosigmoid colon, which was nondistended consistent with patients who have undergone bowel prep. Upon further evaluation of the pelvis, the uterus was somewhat normal-appearing. No significant globular appearance typical of adenomyosis was appreciated, though there was suspicion on preoperative MRI; final pathology is pending. There was surgical absence of the right ovary and bilateral fallopian tubes. The left ovary was normal-appearing with two small simple cysts, which were drained. Over the peritoneum in the pelvic sidewall and fossa were areas of possible endometriosis, which were stripped and excised. An Allen-Master window in the right pararectal space was completely excised. Hysterectomy was performed along with excision and peritoneal stripping of bilateral pelvic sidewalls, ovarian fossa, uterosacral ligaments, and the right perirectal Allen-Master window with removal of possible areas of endometriosis. There were no adhesions in the pelvis, and the posterior cul-de-sac was wide open. Diagnostic cystoscopy at the conclusion of the procedure revealed an intact bladder with no evidence of stitches or defects; bilateral ureteral vigorous jets were noted without complications.

Operative Note Narrative

The patient was brought to the operating room. After confirming correct patient and procedure, general anesthesia was administered. The patient was placed in dorsolithotomy position using Yellofin stirrups, with the right arm out and the left arm tucked in per usual robotic positioning. Tolerance of steep Trendelenburg position was confirmed before starting the procedure. The vaginal portion of the procedure began with insertion of a Foley catheter. A bivalve speculum was placed in the vagina for visualization of the cervix. The cervix was grasped with a single-tooth tenaculum and the uterus was sounded. A RUMI II manipulator was applied with appropriate tip length and cup size. After placement of the uterine manipulator, attention was diverted to the abdominal portion of the case after changing of gloves. Following injection of 0.25% bupivacaine without epinephrine, a 10-mm incision was made at the base of the umbilicus. Dissection was carried through skin, subcutaneous layers, and fascia using sharp dissection. Entry into the peritoneal cavity was achieved without complications. A 10/12 Hasson trocar was placed, and the robotic camera was used to assess the pelvis and upper abdomen, confirming the findings above. Under direct visualization, three accessory robot arms were placed — two on the left side and one on the right. An additional 10-mm step trocar was placed in the right paramedian region as the assistant port. The robot was docked after positioning the patient in complete Trendelenburg. Instruments used included a prograsp (arm 1), Maryland bipolar (arm 2), and monopolar scissors (arm 4). Another survey with the robot camera confirmed findings, and photos were taken. The procedure began on the left side where the retroperitoneum was entered and the ureter identified. Complete ureterolysis was performed from the pelvic brim to the cervical cup as the ureter crossed under the uterine vessels. The overlying peritoneum in the left pelvic sidewall, left ovarian fossa, and left uterosacral ligament was stripped, excised, and sent to pathology. The same was performed on the right side. A rectal probe was inserted to delineate rectal borders before entering the right perirectal space. The Allen-Master window was completely excised. Attention was then turned to creation of the bladder flap. The vesicoperitoneum was tented and entered with monopolar scissors. The incision was extended laterally using monopolar cautery and blunt dissection to reflect the bladder below the cervical cup. Using a vessel sealer bipolar device, the utero-ovarian ligament was clamped, coagulated, and cut. The round ligament was similarly taken down, and the anterior broad ligament peritoneum was connected to the bladder flap. Left ureterolysis had already been performed, so the left uterine vessels were skeletonized and taken at the level of the internal os with the vessel sealer. The same was done on the right side, starting at the right round ligament (right ovary absent), continuing through the anterior leaf of the broad ligament to the bladder flap. The right uterine vessels were skeletonized and taken at the cervical cup level. A colpotomy was performed using monopolar cut energy. Once completed, a ring forceps was introduced through the vagina, and the uterus was removed intact without morcellation or complications. Mild oozing was noted from peritoneal edges and the vaginal cuff. The cuff was reapproximated in two layers using 2-0 V-Lock suture, incorporating the uterosacral ligaments and achieving hemostasis. Palpation confirmed a well-approximated cuff. Suction irrigation confirmed hemostasis. FloSeal was placed over peritoneal edges and vaginal cuff. The robot was undocked, and a diagnostic cystoscopy was performed after removing the Foley catheter. The bladder was intact with no evidence of stitches or injury, and bilateral ureteral jets were observed. The vagina showed no lacerations or tears from specimen removal. The abdomen was re-insufflated after trocar removal. The umbilical fascia was closed with 0 Vicryl in running fashion. Final inspection showed well-approximated fascia and no underlying structure involvement. Pneumoperitoneum was reduced, and skin at all trocar sites was closed with 3-0 Monocryl in subcuticular fashion with Dermabond and Band-Aids applied. Sponge, needle, and instrument counts were correct ×2. The patient was extubated and transferred to recovery in excellent condition.