Primary Surgery for Malignant Large Bowel Obstruction: Postoperative Nasogastric Tube Reinsertion is Not Mandatory

Evaluating the impact of enhanced recovery after surgery protocols following emergency laparotomy - A systematic review and meta-analysis of randomised clinical trials

INTRODUCTION

Enhanced recovery after surgery (ERAS) protocols are an evidence-based, multidisciplinary, and systematic approach to peri-operative care, which attempt to reduce the anticipated physiological strain on patients after major surgery. This meta-analysis of randomised clinical trials (RCTs) evaluated the impact of ERAS following emergency laparotomy versus standard care.

METHODS

A systematic review was performed as per PRISMA guidelines. Meta-analysis was performed using RevMan v5.4.

RESULTS

Six RCTs involving 509 patients were included. Patients randomised to ERAS had reduced post-operative nausea and vomiting (PONV) (odds ratio (OR): 0.32, 95 ​% confidence interval (CI): 0.20-0.51), time to ambulation (mean difference (MD): 1.67, 95 ​% CI: -2.56 to -0.78) and bowel opening (MD: -1.26, 95 ​% CI: -2.03 to -0.49), length of stay (LOS) (MD: -2.92 95 ​% CI: -3.73 - - 2.10), pulmonary complications (OR: 0.43, 95 ​% CI: 0.24-0.75), surgical site (OR: 0.33 95 ​% CI: 0.2-0.50) and urinary tract infections (OR: 0.48 95 ​% CI: 0.19-1.16).

CONCLUSION

ERAS successfully reduced patient recovery, LOS, and complications. ERAS protocols should be deployed, where feasible, for emergency laparotomy.

Medical versus surgical causes of death following colorectal resection: a Queensland Audit of Surgical Mortality (QASM) study

BACKGROUND

The causes of death following colorectal resection remain poorly explored. Few studies have addressed whether early post-operative mortality is predominantly caused by a patient's medical co-morbidities, or from factors pertaining to the presenting surgical disease process itself. This study analyses data from the Queensland audit of surgical mortality (QASM) to report the causes of in-hospital death following colorectal resection, identifies whether these were due to either medical or surgical factors, and determines the patient characteristics associated with a medical cause of death.

METHODS

Through analysis of QASM Surgical Case Forms, the causes of in-hospital death were determined in 750 patients who died in Queensland following colorectal resection between January 2010 and December 2020. Deaths were attributed to a specific medical or surgical cause, with multivariate analysis used to identify independent risk factors associated with a medical cause of death.

RESULTS

In total, 395 patients (52.7%) died due to surgical causes and 355 (47.3%) died due to medical causes. Respiratory co-morbidities (OR 1.832, 95% CI: 1.267-2.650), advanced malignancy (OR 1.814, 95% CI: 1.262-2.607), neurological co-morbidities (OR 1.794, 95% CI: 1.168-2.757) and advanced age (OR 1.430, 95% CI: 1.013-2.017) were independent risk factors associated with increased risk of a medical cause of death.

CONCLUSION

Even in the absence of complicating surgical factors, a significant number of patients died in hospital following colorectal resection due to their underlying co-morbidities. Multi-disciplinary models of care which allow for the early recognition and treatment of medical complications may reduce post-operative mortality in these patients.

Impact of Early Oral Feeding on Nasogastric Tube Reinsertion After Elective Colorectal Surgery: A Systematic Review and Meta-Analysis

Background

Colorectal cancer is a common malignant tumor appearing in the gastrointestinal tract. Surgical resection is recognized as the best means to improve patient survival. However, it is controversial whether early oral feeding (EOF) after elective colorectal resection demonstrates safety and efficacy in concerned clinical outcomes.

Methods

We searched PubMed, Embase, Cochrane Library, and CNKI from inception to September 2021. Two authors independently screened the retrieved records and extracted data. EOF was defined as feeding within 24 h after surgery, while traditional oral feeding (TOF) was defined as feeding that started after the gastrointestinal flatus or ileus was resolved. The primary outcome was nasogastric tube insertion, and the secondary outcomes were the length of hospital stay and total complications. Categorical data were combined using odds ratio (OR), and continuous data were combined using mean difference (MD).

Results

We screened 10 studies from 34 records after full-text reading, with 1,199 patients included in the analysis. Nasogastric tube reinsertion (OR 1.69; 95% CI 1.08 to 2.64, p=0.02) was more frequent in the EOF group, and older ages (>60 years) were associated with higher risk of nasogastric tube reinsertion (OR 2.05; 95% CI 1.05 to 3.99, p = 0.04). Reduced length of hospital stay (MD −1.76; 95% CI −2.32 to −1.21; p < 0.01) and the rate of total complications (OR 0.49; 95% CI 0.37 to 0.65, p < 0.01) were observed in EOF compared with TOF.

Conclusions

EOF was safe and effective for patients undergoing elective colorectal surgery, but the higher rate of nasogastric tube reinsertion compared with TOF should not be ignored.

Risk Factors for Prolonged Postoperative Ileus in Colorectal Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Prolonged postoperative ileus (PPOI) represents a frequent complication following colorectal surgery, affecting approximately 10-15% of these patients. The objective of this study was to evaluate the perioperative risk factors for PPOI development in colorectal surgery.

METHODS

The present systematic review and meta-analysis was conducted in accordance with the PRISMA Statement. PubMed, EMBASE, SciELO, and LILACS databases were searched, without language or time restrictions, from inception until December 2018. The keywords used were: Ileus, colon, colorectal, sigmoid, rectal, postoperative, postoperatory, surgery, risk, factors. The Newcastle-Ottawa scale and the Jadad scale were used for bias assessment, while the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used for quality assessment of evidence on outcome levels.

RESULTS

Of the 64 studies included, 42 were evaluated in the meta-analysis, comprising 29,736 patients (51.84% males; mean age 62 years), of whom 2844 (9.56%) developed PPOI. Significant risk factors for PPOI development were: male sex (OR 1.43; 95% CI 1.25-1.63), age (MD 3.17; 95% CI 1.63-4.71), cardiac comorbidities (OR 1.54; 95% CI 1.19-2.00), previous abdominal surgery (OR 1.44; 95% CI 1.19, 1.75), laparotomy (OR 2.47; 95% CI 1.77-3.44), and ostomy creation (OR 1.44; 95% CI 1.04-1.98). Included studies evidenced a moderate heterogeneity. The quality of evidence was regarded as very low-moderate according to the GRADE approach.

CONCLUSIONS

Multiple factors, including demographic characteristics, past medical history, and surgical approach, may increase the risk of developing PPOI in colorectal surgery patients. The awareness of these will allow a more accurate assessment of PPOI risk in order to take measures to decrease its impact on this population.

Nasogastric tube after small bowel obstruction surgery could be avoided: a retrospective cohort study

PURPOSE

The safety and feasibility of early removal of nasogastric tube (NGT) after small bowel obstruction (SBO) surgery have not yet been assessed. Such a practice could allow to implement enhanced recovery after surgery (ERAS) protocols after acute SBO surgery. The aims of this study were to assess the safety of early NGT removal by comparing the short-term outcomes of patients with postoperative NGTs and those with no postoperative NGT.

METHODS

All patients undergoing surgery for strangulation or adhesive SBO between January the 1st of 2014 and December the 31st of 2017 were retrospectively included.

RESULTS

Among the 123 included, NGT was removed immediately after the end of the procedure in 26 cases (21.1%) and 19 patients required NGT replacement (15.4%). In univariate analysis, early removal of NGT was significantly associated with a reduction of overall morbidity, severe morbidity and postoperative ileus occurrence. Multivariate analysis confirmed that NGT left in place was a risk factor for postoperative ileus [Odd Ratio (OR) 4.9, Confidence Interval (CI) 95% 1.3-19.2; p = 0.02], while it has no incidence on severe morbidity.

CONCLUSIONS

Early NGT removal after ASBO surgery seemed to be feasible, safe and efficient, at least in selected patients. This primary study represents the initial foundations for building the implementation of ERAS protocols after ASBO surgery.

Enhanced recovery after surgery in emergency colorectal surgery: Review of literature and current practices

Enhanced recovery after surgery (ERAS), a multidisciplinary program designed to minimize stress response to surgery and promote the recovery of organ function, has become a standard of perioperative care for elective colorectal surgery. In an elective setting, ERAS program has consistently been shown to decrease postoperative complication, reduce length of hospital stay, shorten convalescence, and lower healthcare cost. Recently, there is emerging evidence that ERAS program can be safely and effectively applied to patients with emergency colorectal conditions such as acute colonic obstruction and intraabdominal infection. This review comprehensively covers the concept and application of ERAS program for emergency colorectal surgery. The outcomes of ERAS program for this emergency surgery are summarized as follows: (1) The ERAS program was associated with a lower rate of overall complication and shorter length of hospital stay - without increased risks of readmission, reoperation and death after emergency colorectal surgery; and (2) Compliance with an ERAS program in emergency setting appeared to be lower than that in an elective basis. Moreover, scientific evidence of each ERAS item used in emergency colorectal operation is shown. Perspectives of ERAS pathway in emergency colorectal surgery are addressed. Finally, evidence-based ERAS protocol for emergency colorectal surgery is presented.

恶性肠梗阻的治疗现状与进展

恶性肠梗阻(malignant bowel obstruction, MBO)是晚期肿瘤常见并发症之一, 严重影响患者的生活质量. 恶性肿瘤本身的复杂性导致肠梗阻治疗的复杂性、难治性. 近年来, 随着腹腔镜、内镜技术及介入技术的发展以及对姑息手术适应证的把握, 肠梗阻患者的生存质量及治疗率得以提高, 但尚存在一定争议, 且在药物治疗方面暂无显著进展. 另外, 中医药在该领域亦有较多研究, 显示出一定的效果, 但尚缺乏前瞻性的随机对照研究. 临床处理要充分考虑治疗可能带来的益处及风险, 慎重选择个性化的治疗方案. 本文对国内外近年来MBO的中西医诊疗进展进行系统综述, 以期对临床诊疗具有一定的指导意义.