Postoperative nonsteroidal anti-inflammatory drugs and risk of anastomotic leak: meta-analysis of clinical and experimental studies

Perioperative Considerations for the Surgical Treatment of Crohn's Disease with Discussion on Surgical Antibiotics Practices and Impact on the Gut Microbiome

Crohn's disease, a chronic inflammatory process of the gastrointestinal tract defined by flares and periods of remission, is increasing in incidence. Despite advances in multimodal medical therapy, disease progression often necessitates multiple operations with high morbidity. The inability to treat Crohn's disease successfully is likely in part because the etiopathogenesis is not completely understood; however, recent research suggests the gut microbiome plays a critical role. How traditional perioperative management, including bowel preparation and preoperative antibiotics, further changes the microbiome and affects outcomes is not well described, especially in Crohn's patients, who are unique given their immunosuppression and baseline dysbiosis. This paper aims to outline current knowledge regarding perioperative management of Crohn's disease, the evolving role of gut dysbiosis, and how the microbiome can guide perioperative considerations with special attention to perioperative antibiotics as well as treatment of Mycobacterium avium subspecies paratuberculosis. In conclusion, dysbiosis is common in Crohn's patients and may be exacerbated by malnutrition, steroids, narcotic use, diarrhea, and perioperative antibiotics. Dysbiosis is also a major risk factor for anastomotic leak, and special consideration should be given to limiting factors that further perturb the gut microbiota in the perioperative period.

PROcedure-SPECific postoperative pain management guideline for laparoscopic colorectal surgery: A systematic review with recommendations for postoperative pain management

Colorectal cancer is the second most common cancer diagnosed in women and third most common in men. Laparoscopic resection has become the standard surgical technique worldwide given its notable benefits, mainly the shorter length of stay and less postoperative pain. The aim of this systematic review was to evaluate the current literature on postoperative pain management following laparoscopic colorectal surgery and update previous procedure-specific pain management recommendations. The primary outcomes were postoperative pain scores and opioid requirements. We also considered study quality, clinical relevance of trial design, and a comprehensive risk-benefit assessment of the analgesic intervention. We performed a literature search to identify randomised controlled studies (RCTs) published before January 2022. Seventy-two studies were included in the present analysis. Through the established PROSPECT process, we recommend basic analgesia (paracetamol for rectal surgery, and paracetamol with either a nonsteroidal anti-inflammatory drug or cyclo-oxygenase-2-specific inhibitor for colonic surgery) and wound infiltration as first-line interventions. No consensus could be achieved either for the use of intrathecal morphine or intravenous lidocaine; no recommendation can be made for these interventions. However, intravenous lidocaine may be considered when basic analgesia cannot be provided.

Non-Surgical Interventions for the Prevention of Clinically Relevant Postoperative Pancreatic Fistula-A Narrative Review

Clinically relevant postoperative pancreatic fistula (CR-POPF) is the leading cause of morbidity and mortality after pancreatic surgery. Post-pancreatectomy acute pancreatitis (PPAP) has been increasingly understood as a precursor and exacerbator of CR-POPF. No longer believed to be the consequence of surgical technique, the solution to preventing CR-POPF may lie instead in non-surgical, mainly pharmacological interventions. Five databases were searched, identifying eight pharmacological preventative strategies, including neoadjuvant therapy, somatostatin and its analogues, antibiotics, analgesia, corticosteroids, protease inhibitors, miscellaneous interventions with few reports, and combination strategies. Two further non-surgical interventions studied were nutrition and fluids. New potential interventions were also identified from related surgical and experimental contexts. Given the varied efficacy reported for these interventions, numerous opportunities for clarifying this heterogeneity remain. By reducing CR-POPF, patients may avoid morbid sequelae, experience shorter hospital stays, and ensure timely delivery of adjuvant therapy, overall aiding survival where prognosis, particularly in pancreatic cancer patients, is poor.

Targeting TRPV1 and TRPA1: A feasible strategy for natural herbal medicines to combat postoperative ileus

Under physiological or pathological conditions, transient receptor potential (TRP) channel vanilloid type 1 (TRPV1) and TRP ankyrin 1 (TRPA1) possess the ability to detect a vast array of stimuli and execute diverse functions. Interestingly, increasing works have reported that activation of TRPV1 and TRPA1 could also be beneficial for ameliorating postoperative ileus (POI). Increasing research has revealed that the gastrointestinal (GI) tract is rich in TRPV1/TRPA1, which can be stimulated by capsaicin, allicin and other compounds. This activation stimulates a variety of neurotransmitters, leading to increased intestinal motility and providing protective effects against GI injury. POI is the most common emergent complication following abdominal and pelvic surgery, and is characterized by postoperative bowel dysfunction, pain, and inflammatory responses. It is noteworthy that natural herbs are gradually gaining recognition as a potential therapeutic option for POI due to the lack of effective pharmacological interventions. Therefore, the focus of this paper is on the TRPV1/TRPA1 channel, and an analysis and summary of the processes and mechanism by which natural herbs activate TRPV1/TRPA1 to enhance GI motility and relieve pain are provided, which will lay the foundation for the development of natural herb treatments for this disease.

Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

Risk of NSAID-associated anastomosis leakage after colorectal surgery: a large-scale retrospective study using propensity score matching

PURPOSE

NSAIDs are commonly used as opioid-sparing analgesics in colorectal surgery. Many efforts are made to elucidate the risk of NSAID-associated anastomotic leakage after colorectal surgery. However, these results still remain controversial. In this study, we applied large-scale retrospective analysis using propensity score matching to fully clarify the association between risk of anastomotic leakage and use of NSAID after colorectal surgery.

METHODS

All colorectal cancer patients receiving operation during February 2008 to August 2018 in our multi-institution medical organization research database were enrolled. It is worthy to mention that only patients requiring re-operation within 21 days after colorectal surgery due to anastomotic leakage were counted as anastomosis leakage. Furthermore, a propensity score TriMatch analysis was performed to prevent from interference of confounding factors.

RESULTS

A total of 10,584 patients were included in this study and divided into three groups, no NSAIDs group, non-selective NSAIDs group, and selective COX-2 inhibitors group, respectively. Before tri-matching analysis, significant differences in anastomotic leakage rate were observed. After propensity score matching analysis, the ratio of anastomotic leakage requiring re-operation occurred in 2.0%, 3.6%, and 2.0% in no NSAIDs, non-selective NSAIDs, and selective COX-2 inhibitors group, respectively. No significant difference was observed in these three groups.

CONCLUSION

These results suggest that NSAIDs are not associated with incidence of anastomosis leakage following colorectal surgery. To our knowledge, it is the first study demonstrating that NSAIDs is not associated with incidence of anastomosis leakage following colorectal surgery using propensity score matching at a larger-scale retrospective study.

Opioid-Sparing Perioperative Analgesia Within Enhanced Recovery Programs

Opioid-based analgesia in the perioperative period can provide excellent pain control, but this approach exposes the patient to avoidable side effects and possible harm. Optimal analgesia, an approach that targets the fastest functional recovery with adequate pain control while minimizing side effects, can be achieved with opioid minimization. Many different options for nonopioid multimodal analgesia exist and have been shown to be efficacious, with certain modalities being more beneficial for specific surgeries. This review will present the evidence and practical tips for these management strategies.

Dissecting the Perioperative Care Bundle

Enhanced recovery after surgery (ERAS) protocols are comprehensive perioperative care pathways designed to mitigate the physiologic stressors associated with surgery and, in turn, improve clinical outcomes and lead to health care cost savings. Although individual components may differ, ERAS protocols are typically organized as multimodal care "bundles" that, when followed closely and in their entirety, are meant to generate amplified cumulative benefits. This manuscript examines some of the critical components, describes some areas where the science is weak (but dogma may be strong), and provides some of the evidence or lack thereof behind components of a standard ERAS protocol.

Impact of Deserosalization on Small Bowel Anastomosis Healing in Swine: A Pilot Study

BACKGROUND

Healing is related to gastrointestinal anastomotic leak, which is a severe and common complication. This study aimed to investigate the feasibility and the impact of deserosalization on healing of jejuno-jejunal anastomoses in an animal model.

MATERIALS AND METHODS

Seven swine underwent three types of side-to-side jejuno-jejunal anastomosis twice and survived seven days. Three different types of jejuno-jejunal side-to-side anastomoses were performed twice at 20-cm distance from each other in each animal: no serosa removal, one-sided, and two-sided serosa removal, respectively. Bursting pressure, tissue hydroxyproline concentration, and pathology scores were evaluated.

RESULTS

Hydroxyproline tissue concentration was a mean±standard deviation of 0.37±0.09, 0.38±0.08, and 0.30±0.05 nmoI/ml respectively (p<0.05). Bursting pressure was a mean±standard deviation of 59.02±8.60, 73.20±11.09, and 100.01±7.49 mmHg, respectively (p<0.001). The histopathological assessment did not find any statistically significant differences.

CONCLUSION

Deserosalization in jejuno-jejunal anastomosis was technically feasible and seemed to improve mechanical strength and collagen deposition in this experimental porcine model. Further investigation is warranted.

Non-steroidal anti-inflammatory agents and anastomotic leak rates across colorectal cancer operations and anastomotic sites: A systematic review and meta-analysis of anastomosis specific leak rate and confounding factors

BACKGROUND

Surgical intervention presents a fundamental therapeutic choice in the management of colorectal malignancies. Complications, the most serious one being anastomotic leak (AL), still have detrimental effects upon patients' morbidity and mortality. We aimed to assess whether NSAIDs, and their sub-categories, increase AL in colonic anastomoses and to identify whether this affects specific anastomotic sites.

MATERIALS AND METHODS

A systematic search of MEDLINE, Cochrane Library, ClinicalTrials.gov, Web of Science, Science Direct, Google Scholar was conducted between January 1, 1999 till the October 30, 2020. Cohort studies and randomized control trials examining AL events in NSAID-exposed, colorectal cancer patients were included. NSAIDs were grouped according to the 2019 NICE guidelines in non-specific (NS-NSAIDs) and specific COX-2 inhibitors. The primary outcome was AL events in NSAID-exposed patients undergoing operations with either ileocolic, colocolic or colorectal anastomoses. Secondary outcomes included NSAID category-specific AL events and demographic confounding factors increasing AL risk in this patient population.

RESULTS

Fifteen studies involving 25,395 patients were included in the systematic review and meta-analysis. Of all anastomoses, colocolic anastomoses were found to be statistically more prone to AL events in the NS-NSAID-exposed population [OR 3.24 (95% CI 0.98-10.72), p = 0.054]. Male gender was an independent confounder increasing AL rate regardless of NSAID exposure.

CONCLUSION

The association between NSAID exposure and AL in oncology patients remains undetermined. Whilst in present work, colocolic anastomoses appear to be more sensitive to AL events, the observed association may be anastomotic site and NSAID-category dependent.

Analgesic Efficacy of Nefopam as an Adjuvant in Patient-Controlled Analgesia for Acute Postoperative Pain After Laparoscopic Colorectal Cancer Surgery

Despite rapid advancements in laparoscopic surgical techniques and perioperative management, postoperative pain remains a significant clinical issue. We examined the analgesic efficacy of nefopam as an adjuvant in patient-controlled analgesia (PCA) for acute postoperative pain in patients undergoing laparoscopic colorectal cancer surgery. We retrospectively analyzed the medical records of 120 patients who did or did not receive 80 mg of nefopam as an adjuvant in fentanyl PCA; they were allocated to the nefopam (n = 60) or non-nefopam group (n = 60). The demographic, clinical, and anesthetic data, with data on pain severity and opioid administration at the postoperative anesthesia care unit (PACU) on postoperative days (PODs) 1, 3, and 5, were compared between the groups. The pain score and opioid administration did not differ at the PACU or on PODs 1, 3, or 5. The day of PCA discontinuation, time to pass flatus, length of the hospital stay, and incidence of nausea/vomiting, dizziness, and headache also did not differ between the groups. Fentanyl PCA with 80 mg of nefopam as an adjuvant did not have a superior analgesic effect after laparoscopic colorectal cancer surgery.

Review of Colonic Anastomotic Leakage and Prevention Methods

Although surgeries involving anastomosis are relatively common, anastomotic leakages are potentially deadly complications of colorectal surgeries due to increased risk of morbidity and mortality. As a result of the potentially fatal effects of anastomotic leakages, a myriad of techniques and treatments have been developed to treat these unfortunate cases. In order to better understand the steps taken to treat this complication, we have created a composite review involving some of the current and best treatments for colonic anastomotic leakage that are available. The aim of this article is to present a background review of colonic anastomotic leakage, as well as current strategies to prevent and treat this condition, for a broader audience, including scientist, engineers, and especially biomedical engineers.

Review of nonopioid multimodal analgesia for surgical and trauma patients

Purpose

Pain is a frequent finding in surgical and trauma patients, and effective pain control remains a common challenge in the hospital setting. Opioids have traditionally been the foundation of pain management; however, these agents are associated with various adverse effects and risks of dependence and diversion.

Summary

In response to the rising national opioid epidemic and the various risks associated with opioid use, multimodal pain management through use of nonopioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs, α 2 agonists, N-methyl-d-aspartate (NMDA) receptor antagonists, skeletal muscle relaxants, sodium channel blockers, and local anesthetics has gained popularity recently. Multimodal analgesia has synergistic therapeutic effects and can decrease adverse effects by enabling use of lower doses of each agent in the multimodal regimen. This review discusses properties of the various nonopioid analgesics and encourages pharmacists to play an active role in the selection, initiation, and dose-titration of multimodal analgesia. The choice of nonopioid agents should be based on patient comorbidities, hemodynamic stability, and the agents’ respective adverse effect profiles. A multidisciplinary plan for management of pain should be formulated during transitions of care and is an area of opportunity for pharmacists to improve patient care.

Conclusion

Multimodal analgesia effectively treats pain while decreasing adverse effects. There is mounting evidence to support use of this strategy to decrease opioid use. As medication experts, pharmacists can play a key role in the selection, initiation, and dose-titration of analgesic agents based on patient-specific factors.

How to reduce anastomotic leakage in colorectal surgery-report from German expert meeting

AIMS

Anastomotic leakage is one of the most worrisome complications in colorectal surgery. An expert meeting was organized to discuss and find a consensus on various aspects of the surgical management of colorectal disease with a possible impact on anastomotic leakage.

METHODS

A three-step Delphi-method was used to find consensus recommendations.

RESULTS

Strong consensus was achieved for the use of mechanical bowel preparation and oral antibiotics prior to colorectal resections, the abundance of non-selective NSAIDs, the preoperative treatment of severe iron deficiency anemia, and for attempting to improve the patients' general performance in the case of frailty. Concerning technical aspects of rectal resection, there was a strong consensus in regard to routinely mobilizing the splenic flexure, to dividing the inferior mesenteric vein, and to using air leak tests to check anastomotic integrity. There was also a strong consensus on not to oversew the stapled anastomoses routinely, to use protective ileostomies for low rectal and intersphincteric, but not for high-rectal anastomoses. Furthermore, a consensus was reached in regard to using CT-scans with rectal contrast enema to evaluate suspected anastomotic leakage as well as measuring C-reactive protein routinely to monitor the postoperative course after colorectal resections. No consensus was found concerning the indication and technique for testing bowel perfusion, the routine use of endoscopy to check the integrity of the anastomosis, the placement of transanal drains for rectal anastomoses and the management of anastomotic leakage with peritonitis.

CONCLUSION

Consensus could be found for several practice details in the perioperative management in colorectal surgery that might have an influence on anastomotic leakage.

Pain management within an enhanced recovery program after thoracic surgery

Evidence for ERAS within thoracic surgery (ERATS) is building. The key to enabling early recovery and ambulation is ensuring that postoperative pain is well controlled. Surgery on the chest is considered to be one of the most painful of surgical procedures for both open and minimally invasive surgery (MIS) approaches. Increasing use of MIS and improved perioperative care pathways has resulted in shorter length of stay (LOS), requiring patients to achieve optimal pain control earlier and meet discharge criteria sooner, sometimes on the same day as surgery. This requires optimizing pain control earlier in the postoperative recovery phase in order to enable ambulation and a better recovery profile, as well as to minimize the risk for development of chronic persistent postoperative pain (CPPP). This review will focus on the options for pain management protocols within an ERAS program for thoracic surgery patients (ERATS).

Changes in Clinical Practice Reduce the Rate of Anastomotic Leakage After Colorectal Resections

Background

Anastomotic leakage is a serious clinical problem after colorectal resections and is associated with a significantly increased length of stay, morbidity and mortality. The aim of the present study was to evaluate the effect of changes in clinical practice on anastomotic leakage rate after colorectal resections.

Methods

Retrospective cohort study based on prospectively collected data. All 894 patients with primary anastomosis after colorectal resection at a tertiary referral center between 2006 and 2013 were analyzed. Changes in clinical practice aiming at reducing the rate of anastomotic leakages were introduced in January 2010 and were characterized by exclusion of perioperative nonsteroidal anti-inflammatory drugs, introduction of intra-operative goal-directed fluid therapy and avoidance of primary anastomoses in emergency resections. The study population was divided into two groups, one treated before and one after the introduction of changes in clinical practice. Groups were compared regarding patient characteristics and incidence of anastomotic leakage.

Results

The cumulative incidence of anastomotic leakage after colorectal resections decreased from 10.0% (41 of 409) to 4.5% (22 of 485) after changing clinical practice, relative risk 0.45 (95% CI 0.27–0.75, p = 0.002). The adjusted odds ratio was 0.45 (0.26–0.78, p = 0.004). A separate analysis showed a decrease after colon resections from 9.1% (23 of 252) to 4.5% (14 of 310), relative risk 0.49 (0.26–0.94, p = 0.039), and from 11.5% (18 of 157) to 4.6% (8 of 175) after rectal resections, relative risk 0.40 (0.18–0.89, p = 0.024).

Conclusion

Implementing a structured change of clinical practice can significantly reduce the anastomotic leakage rate after colorectal resections.

Trial registration

Clinical trial registration number: ACTRN12617001497392.

Experimental study of diclofenac and its biliary metabolites on anastomotic healing

Background

Diclofenac increases the risk of anastomotic leakage, but the underlying mechanism is unknown. As diclofenac is excreted largely as biliary metabolites, the aim of this study was to determine the effect of these metabolites on intestinal anastomoses.

Methods

This was a randomized controlled blinded experiment using 210 male Wistar rats to assess the effect of ‘diclofenac bile’ on the anastomotic complication score, leak rate and anastomotic strength following oral and parenteral administration of diclofenac. Bile duct and duodenal catheterization techniques were used for diversion and replacement of bile, and biliary diclofenac metabolites were determined.

Results

Replacement of control bile with diclofenac bile resulted in higher anastomotic complication scores (P = 0·006) and leakage in five of 18 animals, compared with one of 18 controls (P = 0·089). In turn, following oral diclofenac administration, replacement of diclofenac bile with control bile reduced anastomotic complications (P = 0·016). The leak rate was seven of 15 versus 13 of 17 without replacement (P = 0·127). After intramuscular administration of diclofenac, the reduction in anastomotic complications was not significant when bile was replaced with control bile (P = 0·283), but it was significant when bile was drained without replacement (P = 0·025). Diclofenac metabolites in bile peaked within 2 h after administration. Administration of diclofenac bile resulted in nearly undetectable plasma levels of diclofenac (mean(s.d.) 0·01(0·01) μg/ml) after 120 min. Following oral diclofenac, bile replacement with control bile did not affect the plasma concentration of diclofenac (0·12(0·08) μg/ml versus 0·10(0·05) μg/ml with diclofenac bile; P = 0·869).

Conclusion

Altered bile composition as a result of diclofenac administration increases the ileal anastomotic complication rate in rats.

Efficacy of Nalbuphine with Flurbiprofen on Multimodal Analgesia with Transverse Abdominis Plane Block in Elderly Patients Undergoing Open Gastrointestinal Surgery: A Randomized, Controlled, Double-Blinded Trial

Objective

To assess different doses of nalbuphine with flurbiprofen compared to sufentanil with flurbiprofen in multimodal analgesia efficacy for elderly patients undergoing gastrointestinal surgery with a transverse abdominis plane block (TAPB).

Methods

158 elderly patients scheduling for elective open gastrointestinal surgery under general anesthesia and TAPB were randomly assigned to four groups according to different doses of nalbuphine with flurbiprofen in postoperative intravenous analgesia (PCIA). Postoperative pain intensity, effective pressing numbers of PCIA, and adverse effects were recorded at 6, 12, 24, and 48 hours after surgery.

Results

Postoperative pain intensity, effective pressing numbers, and the incidence of postoperative nausea and vomiting (PONV) were similar among the four groups after surgery, while the severity of PONV was decreased in Group L compared with Group S at 6, 12, and 48 h after surgery. No individual experienced pruritus, respiratory depression, or hypotension.

Conclusions

Low dose of nalbuphine (15 μg·kg⁻¹·ml⁻¹) combined with flurbiprofen is superior for elderly patients undergoing elective open gastrointestinal surgery with TAPB in terms of the efficient postoperative analgesia and decreased severity of PONV. This trial is registered with NCT02984865.

Ketorolac use may increase risk of postoperative pancreatic fistula after pancreaticoduodenectomy

BACKGROUND

Ketorolac (Toradol), a commonly used nonselective nonsteroidal anti-inflammatory drug (NSAID) in the postoperative period, has been associated with increased risk of anastomotic leak after colon resection. The effect of postoperative NSAID and ketorolac use on postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) is unknown.

METHODS

Retrospective review of consecutive PDs at a high-volume pancreas center from 2012 to 2015. POPF was identified and graded using International Study Group on Pancreatic Fistula criteria. Demographics, operative variables and 30-d postoperative NSAID use, dosage, and timing (early = postoperative day [POD] 0-5, late > POD 5) were collected. Univariate and multivariate logistic regressions were used to identify predictors of POPF.

RESULTS

Four hundred twenty-three PDs were analyzed (mean age 66 y, 47% female), and 60% received NSAIDs postoperatively. Ketorolac (median POD 0-5 cumulative dose = 90 mg, interquartile range 60-165) was used in 35.7% (n = 151). POPF occurred in 90 patients (21.3%). Early (POD 0-5) ketorolac use was associated with increased POPF, especially grade A (odds ratio [OR] 2.16, P = 0.036). Each 25 mg incremental increase in ketorolac use was associated with a 10% increase in the incidence of POPF (OR 1.10, P = 0.021), whereas a cumulative dose of >150 mg was associated with a 44% increased risk of POPF (OR 1.44, 95% confidence interval 1.03-2.01, P = 0.035). A multivariate regression model identified estimated blood loss, soft gland, pancreatic duct diameter, body mass index, and cumulative ketorolac dose >150 mg as independent predictors of POPF (P < 0.0001, pseudo R² = 0.149).

CONCLUSIONS

Increasing doses of ketorolac in the early postoperative period are associated with increased risk of POPF, whereas a cumulative dose of >150 mg is an independent predictor of POPF after PD.

Effect of Perioperative Dexamethasone and Different NSAIDs on Anastomotic Leak Risk: A Propensity Score Analysis

Background

Perioperative use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with risk of anastomotic leak (AL). However, concomitant use of other drugs could infer a bias in risk assessment. Thus, we aimed to interrogate the risk of AL associated with NSAIDs and steroids used perioperatively.

Methods

This study includes a consecutive series of patients having surgery involving an intestinal anastomosis from Jan 2007 to Dec 2009. Data records included demographic, perioperative, and surgical characteristics; AL rates; and use of NSAIDs and steroids. Risk of leak were estimated using unadjusted and multivariable (propensity score)-adjusted logistic regression models and reported as odds ratios (ORs).

Results

A total of 376 patients underwent 428 operations of which 67 (15.7 %) had AL. With no medication receivers as reference, the OR for leak when adjusted for age, sex, and propensity score was 1.07 (p = 0.92) for ketorolac, 1.63 (p = 0.31) for diclofenac and 0.41 (p = 0.19) for dexamethasone. Risk was increased for malignancy (OR 1.88, p = 0.023), use of a vasopressor (OR 2.52, p = 0.007), blood transfusions (OR 1.93, p = 0.026), and regular use of steroids (OR 7.57, p = 0.009).

Conclusions

Other factors than perioperative drugs are crucial for risk of AL. Perioperative dexamethasone was associated with a nonsignificant reduced risk of AL.

Perioperative use of nonsteroidal anti-inflammatory drugs and the risk of anastomotic failure in emergency general surgery

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used analgesic and anti-inflammatory adjuncts. Nonsteroidal anti-inflammatory drug administration may potentially increase the risk of postoperative gastrointestinal anastomotic failure (AF). We aim to determine if perioperative NSAID utilization influences gastrointestinal AF in emergency general surgery (EGS) patients undergoing gastrointestinal resection and anastomosis.

METHODS

Post hoc analysis of a multi-institutional prospectively collected database was performed. Anastomotic failure was defined as the occurrence of a dehiscence/leak, fistula, or abscess. Patients using NSAIDs were compared with those without. Summary, univariate, and multivariable analyses were performed.

RESULTS

Five hundred thirty-three patients met inclusion criteria with a mean (±SD) age of 60 ± 17.5 years, 53% men. Forty-six percent (n = 244) of the patients were using perioperative NSAIDs. Gastrointestinal AF rate between NSAID and no NSAID was 13.9% versus 10.7% (p = 0.26). No differences existed between groups with respect to perioperative steroid use (16.8% vs. 13.8%; p = 0.34) or mortality (7.39% vs. 6.92%, p = 0.84). Multivariable analysis demonstrated that perioperative corticosteroid (odds ratio, 2.28; 95% confidence interval, 1.04-4.81) use and the presence of a colocolonic or colorectal anastomoses were independently associated with AF. A subset analysis of the NSAIDs cohort demonstrated an increased AF rate in colocolonic or colorectal anastomosis compared with enteroenteric or enterocolonic anastomoses (30.0% vs. 13.0%; p = 0.03).

CONCLUSION

Perioperative NSAID utilization appears to be safe in EGS patients undergoing small-bowel resection and anastomosis. Nonsteroidal anti-inflammatory drug administration should be used cautiously in EGS patients with colon or rectal anastomoses. Future randomized trials should validate the effects of perioperative NSAIDs use on AF.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Enhanced Recovery After Surgery in Laparoscopic Surgery

BACKGROUND

As part of an effort to maximize value in the perioperative setting, a paradigm shift is underway in the way that patients are cared for preoperatively, on the day of surgery, and postoperatively-a setting collectively known as the perioperative care. Enhanced Recovery After Surgery (ERAS^®) is an evidence-based, patient-centered team approach to delivering high-quality perioperative care to surgical patients.

METHODS

This review focuses on anesthesiologists, with their unique purview of perioperative setting, who are important drivers of change in the delivery of valuable perioperative care. ERAS care pathways begin in the preoperative setting by both preparing the patient for the psychological stress of surgery and optimizing the patient's medical and physiologic status so the body is ready for the physical demands of surgery.

RESULTS

Minimization of perioperative fasting is important to maintain volume status-decreasing reliance on intravenous fluid administration, and to reduce protein catabolism around the time of surgery. Intraoperative management in ERAS pathways relies on goal-directed fluid therapy and opioid-sparing multimodal analgesia. Postoperatively, early feeding and ambulation, as well as discontinuation of extraneous lines and catheters facilitate patients' functional recovery.

CONCLUSION

The laparoscopic approach to surgery, when possible, compliments ERAS techniques by reducing abdominal wall trauma and the resultant milieu of inflammatory, neurohumoral, and pain responses. Anesthesiologists driving change in the perioperative setting, in collaboration with surgeons and other disciplines, can improve value in healthcare and provide optimal outcomes that matter most to patients and healthcare providers alike.

Nonsteroidal anti-inflammatory drugs and the risk of anastomotic leakage after anterior resection for rectal cancer

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been widely used in colorectal surgery due to their opioid-sparing effect. However, several studies have indicated an increased risk of anastomotic leakage following NSAID treatment, although conflicting results exist. The primary goal of this study was to further examine whether postoperative NSAIDs are independently associated with anastomotic leakage after anterior resection for rectal cancer.

METHODS

Patients who underwent anterior resection for rectal cancer during 2007-2013 in 15 different hospitals in three healthcare regions in Sweden were included in the study. Registry data and information from patient records were retrieved. The association between NSAID treatment (for at least two days in the first postoperative week) and symptomatic anastomotic leakage (within 90 days) was evaluated with multiple logistic regression, with adjustment for pertinent confounding factors.

RESULTS

Some 1495 patients were included in the study. Of these, 27% received postoperative NSAIDs for at least two days in the first postoperative week. Symptomatic anastomotic leakage occurred in 11% and 14% in the NSAID and non-NSAID group, respectively. With adjustment for confounders, the odds ratio for leakage among patients who received NSAIDs compared with those who did not was 0.88 (95% CI 0.65-1.20). No differences were seen between non-selective and COX-2-selective NSAIDs.

CONCLUSION

Postoperative NSAID treatment does not seem to increase the risk of symptomatic anastomotic leakage after anterior resection for rectal cancer. NSAID use appears to be safe, but a well-powered randomized clinical trial is warranted.

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1-from the preoperative period to PACU

Background

Within an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver “optimal analgesia,” which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects.

Methods

With input from a multi-disciplinary, international group of clinicians, and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients.

Discussion

As a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery ERP. The goal was two-fold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus from the preoperative period to the post-anesthesia care unit. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of optimal analgesia as set forth in this document.

Influence of perioperative nonsteroidal anti-inflammatory drugs on complications after gastrointestinal surgery: A meta-analysis

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a key part of multimodal perioperative analgesia. This study aimed to evaluate the influence of perioperative NSAIDs application on complications after gastrointestinal surgery by using meta-analysis.

METHODS

A systematic review of published literature was conducted by searching computerized databases including PubMed, CBM, Springer, Chinese Academic Journals, and China Info since the databases were published until June 2015. The articles and retrospective references regarding complications after gastrointestinal surgery were collected to compare postoperative complications associated with NSAIDs or other analgesics. After they were assessed by randomized controlled trials and extracted by the standard of the Jadad systematic review, the homogeneous studies were pooled using RevMan 5.3 software. The meta-analysis was performed on five postoperative complications: postoperative anastomotic leak, cardiovascular events, surgical site infection, nausea and vomiting, and intestinal obstruction.

RESULTS

Twelve randomized controlled trials involving 3829 patients met the inclusion criteria. The results of meta-analyses showed the following: (1) postoperative anastomotic leak: NSAIDs (including selective and nonselective NSAIDs) increased the incidence of anastomotic leak [odds ratio (OR)=3.02, 95% confidence interval (CI): 2.16-4.23, p=0.00001]. Further results showed that nonselective NSAIDs significantly increased the incidence of anastomotic leak (OR=2.96, 95% CI: 1.99-4.42, p<0.00001), and selective NSAIDs had no significant difference as compared with the control group using other analgesics (OR=2.27, 95% CI: 0.68-7.56, p=0.18); (2) postoperative cardiovascular events: NSAIDs (selective and nonselective NSAIDs) had no difference when compared with other analgesics (OR=0.50, 95% CI: 0.23-1.12, p=0.09); (3) postoperative surgical site infection: NSAIDs (selective and nonselective NSAIDs) and other analgesics had no difference in surgical site infection (OR=0.77, 95% CI: 0.52-1.15, p=0.20); (4) postoperative nausea and vomiting: NSAIDs (selective and nonselective NSAIDs) decreased the incidence of nausea and vomiting (OR=0.53, 95% CI: 0.34-0.81, p=0.003); (5) postoperative intestinal obstruction: NSAIDs (selective and nonselective NSAIDs) decreased the incidence of intestinal obstruction (OR=0.35, 95% CI: 0.13-0.89, p=0.03).

CONCLUSIONS

The meta-analysis suggests that postoperative NSAIDs, especially nonselective NSAIDs, could increase the incidence of anastomotic leak. NSAIDs could decrease postoperative nausea and vomiting and intestinal obstruction, but showed no difference in cardiovascular events and surgical site infection as compared with other analgesics.

PANSAID - PAracetamol and NSAID in combination: study protocol for a randomised trial

BACKGROUND

Effective postoperative pain management is essential for the rehabilitation of the surgical patient. No 'gold standard' exists after total hip arthroplasty (THA) and combinations of different nonopioid medications are used with virtually no evidence for additional analgesic efficacy compared to monotherapy. The objective of this trial is to investigate the analgesic effects and safety of paracetamol and ibuprofen alone and in combination in different dosages after THA.

METHODS

PANSAID is a placebo-controlled, parallel four-group, multicentre trial with centralised computer-generated allocation sequence and allocation concealment and with varying block size and stratification by site. Blinding of assessor, investigator, caregivers, patients and statisticians. Patients are randomised to four groups: (A) paracetamol 1 g × 4 and ibuprofen 400 mg × 4, (B) paracetamol 1 g × 4 and placebo, (C) placebo and ibuprofen 400 mg × 4 and (D) paracetamol 0.5 g × 4 and ibuprofen 200 mg. The two co-primary outcomes are 24-h consumption of morphine and number of patients with one or more serious adverse events within 90 days after surgery. Secondary outcomes are pain scores during mobilisation and at rest at 6 and 24 h postoperatively, and number of patients with one or more adverse events within 24 h postoperatively. Inclusion criteria are patients scheduled for unilateral, primary THA; age above 18 years; ASA status 1-3; BMI >18 and <40 kg/m²; women must not be pregnant; and provision of informed consent. Exclusion criteria are patients who cannot cooperate with the trial; participation in another trial; patients who cannot understand/speak Danish; daily use of strong opioids; allergy against trial medication; contraindications against ibuprofen; alcohol and/or drug abuse. A total of 556 eligible patients are needed to detect a difference of 10 mg morphine i.v. the first 24 h postoperatively with a standard deviation of 20 mg and a family wise type 1 error rate of 0.025 (two-sided) and a type 2 error rate of 0.10 for the six possible comparisons of the four intervention groups.

DISCUSSION

We started recruiting patients in December 2015 and expect to finish in September 2017. Data analysis will be from September 2017 to October 2017 and manuscript submission ultimo 2017.

TRIAL REGISTRATION

EudraCT: 2015-002239-16 (12/8-15); ClinicalTrials.gov: NCT02571361 . Registered on 7 October 2015.

A Postoperative Systemic Inflammation Score Predicts Short- and Long-Term Outcomes in Patients Undergoing Surgery for Colorectal Cancer

BACKGROUND

Following surgery, a significant proportion of patients develop postoperative complications that are associated with poorer long-term survival. Stereotypical markers of the systemic inflammatory response (SIR) have been shown to identify patients at increased risk of developing such complications. The aim of the present study was to examine the prognostic value of a postoperative systemic inflammation-based score in patients undergoing potentially curative surgery for colorectal cancer.

METHODS

Patients with histologically proven colorectal cancer undergoing resection between 1999 and 2013 (n = 813) were grouped into two cohorts-a retrospective test cohort (n = 402) and a prospective validation cohort (n = 411). Patients were assessed for postoperative complications and had routine blood samples taken daily. The relationship between markers of the postoperative SIR and survival was examined using Cox regression analysis.

RESULTS

In the test cohort, 87 patients developed an infective complication, while in the validation cohort, 106 patients developed an infective complication. In both cohorts, the postoperative SIR (C-reactive protein and albumin thresholds of >150 mg/L and <25 g/L, respectively) were associated with the development of infective complications (all p < 0.01). Using these thresholds, a scoring system [postoperative Glasgow prognostic score (poGPS)] was created, and on days 3 and 4 was associated with an incremental increase in the infective complication rate (all p < 0.001) and complication severity (p < 0.001). In the overall cohort, there were 175 cancer and 139 non-cancer deaths. The poGPS was also significantly associated with overall survival (p < 0.05).

CONCLUSIONS

The postoperative SIR, evidenced by the poGPS, was associated with increased complication rates and severity and a reduction in survival.

Postoperative Nonsteroidal Anti-inflammatory Drug Use and Intestinal Anastomotic Dehiscence: A Systematic Review and Meta-Analysis

BACKGROUND

Nonsteroidal anti-inflammatory drugs are commonly used analgesics in colorectal surgery. Controversy exists regarding the potential association between these drugs and anastomotic dehiscence.

OBJECTIVE

This study aimed to determine whether postoperative nonsteroidal anti-inflammatory drug use is associated with intestinal anastomotic dehiscence.

DATA SOURCES

PubMed, EMBASE, CENTRAL, and references of included articles were searched without date or language restriction.

STUDY SELECTION

Randomized controlled trials and observational studies that compared postoperative nonsteroidal anti-inflammatory drug use with nonuse and reported on intestinal anastomotic dehiscence were selected.

INTERVENTION

The use of postoperative nonsteroidal anti-inflammatory drugs relative to placebo or nonuse was investigated.

MAIN OUTCOME MEASURES

Risk ratios and adjusted or unadjusted odds ratios for anastomotic dehiscence were pooled across randomized controlled trials and observational studies using DerSimonian and Laird random-effects models.

RESULTS

Among 4395 citations identified, 6 randomized controlled trials (n = 473 patients) and 11 observational studies (n > 20,184 patients) were included. Pooled analyses revealed that nonsteroidal anti-inflammatory drug use was nonsignificantly associated with anastomotic dehiscence in randomized controlled trials (risk ratio, 1.96; 95% CI, 0.74-5.16; I = 0%) and significantly associated with anastomotic dehiscence in observational studies (OR, 1.46; 95% CI, 1.14-1.86; I = 54%). In stratified analyses of observational study data, the pooled OR for anastomotic dehiscence was statistically significant for studies of nonselective nonsteroidal anti-inflammatory drug use (6 studies; > 4900 patients; OR, 2.09; 95% CI, 1.65-2.64; I = 0%), but was not statistically significant for studies of cyclooxygenase-2 selective nonsteroidal anti-inflammatory drug use (3 studies; >697 patients; OR, 1.34; 95% CI, 0.78-2.31; I = 0%).

LIMITATIONS

Studies varied by patient selection criteria, drug exposures, and definitions of anastomotic dehiscence. Analyses of randomized controlled trials and cyclooxygenase-2 selective nonsteroidal anti-inflammatory drugs were potentially underpowered.

CONCLUSIONS

Pooled observational data suggest an association between postoperative nonsteroidal anti-inflammatory drug use and intestinal anastomotic dehiscence. Caution may be warranted in using these medications in patients at risk for this complication.

Opioid-sparing effect of selective cyclooxygenase-2 inhibitors on surgical outcomes after open colorectal surgery within an enhanced recovery after surgery protocol

AIM: To evaluate the opioid-sparing effect of selective cyclooxygenase-2 (COX-2) inhibitors on short-term surgical outcomes after open colorectal surgery.

METHODS: Patients undergoing open colorectal resection within an enhanced recovery after surgery protocol from 2011 to 2015 were reviewed. Patients with combined general anesthesia and epidural anesthesia, and those with acute colonic obstruction or perforation were excluded. Patients receiving selective COX-2 inhibitor were compared with well-matched individuals without such a drug. Outcome measures included numeric pain score and morphine milligram equivalent (MME) consumption on postoperative day (POD) 1-3, gastrointestinal recovery (time to tolerate solid diet and time to defecate), complications and length of postoperative stay.

RESULTS: There were 75 patients in each group. Pain score on POD 1-3 was not significantly different between two groups. However, MME consumption and MME consumption per kilogram body weight on POD 1-3 was significantly less in patients receiving a selective COX-2 inhibitor (P < 0.001). Median MME consumption per kilogram body weight on POD 1-3 was 0.09, 0.06 and nil, respectively in patients receiving a selective COX-2 inhibitor and 0.22, 0.25 and 0.07, respectively in the comparative group (P < 0.001), representing at least 59% opioid reduction. Patients prescribing a selective COX-2 inhibitor had a shorter median time to resumption of solid diet [1 (IQR 1-2) d vs 2 (IQR 2-3) d; P < 0.001] and time to first defecation [2 (IQR 2-3) d vs 3 (IQR 3-4) d; P < 0.001]. There was no significant difference in overall postoperative complications between two groups. However, median postoperative stay was significantly 1-d shorter in patients prescribing a selective COX-2 inhibitor [4 (IQR 3-5) d vs 5 (IQR 4-6) d; P < 0.001].

CONCLUSION: Perioperative administration of oral selective COX-2 inhibitors significantly decreased intravenous opioid consumption, shortened time to gastrointestinal recovery and reduced hospital stay after open colorectal surgery.

Postoperative analgesia using fentanyl plus celecoxib versus epidural anesthesia after laparoscopic colon resection

PURPOSE

Effective postoperative analgesia is essential to a patient's recovery after laparoscopic colon resection (LCR). We introduce a new analgesic protocol using fentanyl plus celecoxib following LCR.

METHODS

The subjects of this retrospective comparative study were 137 patients who underwent LCR, 63 of whom were treated with 72 h of epidural anesthesia (group E), and 74 of whom were treated with 24 h of fentanyl intravenous injection followed by 7 days of oral celecoxib (group FC). We evaluated the safety and efficacy of this new protocol.

RESULTS

The combination of fentanyl and celecoxib maintained a low postoperative pain score (<1.5, evaluated by the FACES Pain Scale) and reduced the need for rescue analgesic drugs for 7 days (groups E vs. FC: 5.39 ± 3.77 vs. 2.79 ± 2.92, p < 0.001). The postoperative hospital stay was almost equal for the two groups (E vs. FC: 11.1 ± 4.5 vs. 10.3 ± 4.8 days, p = 0.315). The operating room stay other than for surgery was significantly shorter for group FC (E vs. FC: 128.7 ± 30.5 vs. 107.2 ± 17.0 min, p < 0.001). Neither group experienced complications, apart from one group FC patient, who suffered transient nausea and vertigo.

CONCLUSIONS

The new analgesic protocol using fentanyl plus celecoxib is an effective and time-saving strategy for LCR.

Effects of Lornoxicam on Anastomotic Healing: A Randomized, Blinded, Placebo-Control Experimental Study

Introduction and Aim. With the implementation of multimodal analgesia regimens, Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) are often administered for optimal pain control and reduction of opioid use. The aim of the study was to examine the effects of lornoxicam, a NSAID, on anastomotic healing employing an animal model. Materials and Methods. A total of 28 Wistar rats were randomly assigned in two groups. All animals underwent ascending colonic transection followed by an end-to-end hand sewn anastomosis. Group 1 received intraperitoneally lornoxicam before and daily after surgery. Group 2 received intraperitoneally an equal volume of placebo. Half of the animals in each group were euthanized on the 3rd pod and the remaining on the 7th pod. Macro- and microscopic indicators of anastomotic healing were compared using a two-tailed Fisher exact test. Results. The lornoxicam group significantly decreased fibroblast in growth and reepithelization of the mucosa at the anastomotic site on the 3rd pod and significantly increased occurrence of deep reaching defects, necrosis, and microabscess on the 7th pod. Conclusion. Lornoxicam administration during the perioperative period adversely affects histologic parameters of intestinal anastomotic healing. These effects of lornoxicam administration were not found to induce significant increase of anastomotic dehiscence in the rat model.