Incidence and predictors of prolonged postoperative ileus after colorectal surgery in the context of an enhanced recovery pathway

Postoperative ileus-Establishing a porcine model

BACKGROUND

Postoperative ileus (POI), characterized by absent gastrointestinal motility, is a frequent complication following major abdominal surgery, with no current effective treatment possibilities. For further research in the treatment of this condition, we aimed to establish a porcine model of POI.

METHODS

A total of 12 Landrace pigs, weighing 60 kg, were included. Five animals were used as pilots to establish the surgical procedure, five animals received the same reproducible surgical procedure developed in the pilot experiments, while two animals were used as control. The primary endpoint was number of days to first stool. Intestinal motility was monitored using the SmartPill system.

KEY RESULTS

Four of the five pigs who underwent the final surgical procedure passed first stool on the third postoperative day (POD), and one passed first stool on the fifth POD. SmartPill data showed retention of the capsule in the stomach in four of five pigs with usable traces.

CONCLUSION AND INFERENCES

An experimental porcine model of POI was established, forming the basis for future studies in POI.

ERAS and Gastrointestinal Site Infections: Insights from a Comprehensive Systematic Review and Meta-Analysis

Background: Enhanced recovery after surgery (ERAS) protocols are proposed to enhance perioperative care, but their impact on various surgical outcomes requires further insight. Objective: This extensive meta-analysis aimed to systematically estimate the effectiveness of ERAS in reducing postoperative complications and improving recovery metrics. Materials and Methods: We meticulously searched multiple databases and rigorously screened studies, ultimately including 16 high-quality research articles in our meta-analysis. We carefully assessed heterogeneity using the Cochran Q test and I2 index. Results were visualized using forest plots, displaying effect sizes and 95% confidence intervals (CIs). Results: The current meta-analysis reveals compelling evidence of ERAS protocols' impact on postoperative effects. Lung infection rates were significantly reduced, with an odds ratio (OR) of 0.4393 (95% CI: 0.2674; 0.7216, p = 0.0012), highlighting the protocols' effectiveness. Although the reduction in surgical site infections (SSIs) was not significant, with an OR of 0.8003 (95% CI: 0.3908; 1.6389, p = 0.5425), the data suggests a trend toward benefit. Urinary tract infections (UTI) also showed a promising decrease, with an OR of 0.4754 (95% CI: 0.2028; 1.1143, p = 0.0871), revealing ERAS protocols may mitigate UTI risks. No significant effects were observed on postoperative anastomotic leakage or ileus, with ORs indicating neutrality. The incidence of readmission was similarly unaffected, with an OR of 1.4018 (95% CI: 0.6860; 2.8647, p = 0.3543). These outcomes underscore the selective efficacy of ERAS protocols, advocating for their strategic implementation to optimize surgical recovery. Conclusions: This meta-analysis offers compelling evidence supporting the implementation of ERAS in mitigating specific post-surgical conditions. It underscores the potential of ERAS to enhance recovery experiences and improve healthcare efficiency. Further targeted research is warranted to fully understand the impact of ERAS on SSI, anastomotic leakage, ileus, and readmissions and to optimize its benefits across diverse surgical populations.

Personalized risk prediction for prolonged ileus after minimally invasive colorectal cancer surgery: in-depth risk factor analysis and model development

PURPOSE

Despite the increasing preference for minimally invasive surgery for colorectal cancer (CRC), the incidence of prolonged postoperative ileus (PPOI) remains high. Thus, this study aimed to identify risk factors for PPOI in patients with CRC who underwent minimally invasive surgery (MICRS) and to develop a practical nomogram for predicting individual PPOI risk.

METHODS

A consecutive series of 2368 patients who underwent MICRS between 2013 and 2023 at two tertiary academic centers were retrospectively studied. Using the data from 1895 patients in the training cohort, a multivariable logistic regression model was employed to select significant variables for the construction of a best-fit nomogram. The nomogram was internally and externally validated.

RESULTS

PPOI occurred in 9.5% of patients. Six independent risk factors were identified to construct a nomogram: advanced age (OR 1.055, P = 0.002), male sex (OR 2.914, P = 0.011), age-adjusted Charlson comorbidity index ≥ 6 (OR 2.643, P = 0.025), preoperative sarcopenia (OR 0.857, P = 0.02), preoperative prognostic nutritional index (OR 2.206, P = 0.047), and intraoperative fluid overload (OR 2.227, P = 0.045). The AUCs of the model for predicting PPOI in the training and external validation cohorts were 0.887 and 0.838, respectively. The calibration curves demonstrated excellent consistency between the nomogram-predicted and observed probabilities in both cohorts. Individuals with a total nomogram score of < 197 or ≥ 197 were considered to be at low or high risk for PPOI, respectively.

CONCLUSIONS

The integrated nomogram we developed could provide personalized risk prediction of PPOI after MICRS. This quantification enables surgeons to implement personalized prevention strategies, thereby improving patient outcomes.

Machine learning prediction model for postoperative ileus following colorectal surgery

BACKGROUND

Postoperative ileus (POI) continues to be a major cause of morbidity following colorectal surgery. Despite best efforts, the incidence of POI in colorectal surgery remains high (~30%). This study aimed to investigate machine learning techniques to identify risk factors for POI in colorectal surgery patients, to help guide further preventative strategies.

METHODS

A TRIPOD-guideline-compliant retrospective study was conducted for major colorectal surgery patients at a single tertial care centre (2018-2022). The primary outcome was the occurrence of POI, defined as not achieving GI-2 (outcome measure of time to first stool and tolerance of oral diet) by day four. Multivariate logistic regression, decision trees, radial basis function and multilayer perceptron (MLP) models were trained using a random allocation of patients to training/testing data sets (80/20). The area under the receiver operating characteristic (AUROC) curves were used to evaluate model performance.

RESULTS

Of 504 colorectal surgery patients, 183 (36%) experienced POI. Multivariate logistic regression, decision trees, radial basis function and MLP models returned an AUROC of 0.722, 0.706, 0.712 and 0.800, respectively. The MLP model had the highest sensitivity and specificity values. In addition to well-known risk factors for POI, such as postoperative hypokalaemia, surgical approach, and opioid use, the MLP model identified sarcopenia (ranked 4/30) as a potentially modifiable risk factor for POI.

CONCLUSION

MLP outperformed other models in predicting POI. Machine learning can provide valuable insights into the importance and ranking of specific predictive variables for POI. Further research into the predictive value of preoperative sarcopenia for POI is required.

Short-term outcome of intracorporeal ileocolonic anastomosis in patients with visceral obesity

The primary objective of this study was to compare short-term outcomes between Intracorporeal ileocolic anastomosis (IIA) and extracorporeal ileocolic anastomosis (EIA) after laparoscopic right hemicolectomy in patients with visceral obesity. The secondary objective was to identify risk factors associated with prolonged postoperative ileus (PPOI) after laparoscopic right hemicolectomy. This single-center retrospective study analyzed visceral obesity patients who underwent laparoscopic right hemicolectomy for primary bowel cancer between January 2020 and June 2023. Patients were categorized into IIA and EIA groups based on the type of anastomosis, and a 1:1 propensity score-matched analysis was performed. A total of 129 patients were initially included in this study, with 45 patients in each group following propensity score matching. The IIA group had significantly longer anastomosis times (p < 0.001), shorter incision length (p < 0.001), and shorter length of stay (p = 0.003) than the EIA group. Meanwhile, the IIA group showed a shorter time to first flatus (p = 0.044) and quicker tolerance of a solid diet (p = 0.030). On multivariate analysis, postoperative use of opioid analgesics is an independent risk factor for PPOI (OR: 3.590 95% CI 1.033-12.477, p = 0.044), while IIA is an independent protective factor (OR: 0.195 95% CI 0.045-0.843, p = 0.029). IIA remains a safe and feasible option for visceral obesity patients. It is also associated with a quicker recovery of bowel function and shorter length of stay when compared to EIA. Additionally, IIA is an independent protective factor for PPOI.

Effectiveness of acupuncture combined with auricular acupressure in the treatment of postoperative ileus: a study protocol for a randomized controlled trial

Background

About one-third of patients experience postoperative ileus (POI) after abdominal surgery, which can cause various complications and has not been treated well in clinical practice. The comprehensive treatment offered by traditional Chinese medicine may be a good choice for promoting intestinal mobility. Therefore, the aim of this study protocol is to observe the effectiveness of acupuncture combined with auricular acupressure in decreasing the incidence and related symptoms of POI.

Methods

This is a single-center, assessor-blinded, randomized controlled trial. A total of 160 participants are supposed to recruit at Shanghai Tenth People's Hospital and randomly divided into two parallel groups in a 1:1 ratio. The intervention group are planned to receive manual acupuncture combined with auricular acupressure, while the control group are planned to receive regular enhanced recovery after surgery treatment. The primary outcome is the time to first defecation and first flatus after surgery. The secondary outcomes include the length of postoperative hospital stay, intensity of postoperative abdominal pain and distension, severity of postoperative nausea and vomiting, time to tolerate diet, inflammatory index, and incidence of prolonged postoperative ileus.

Discussion

The results of this research will provide substantial evidence regarding the efficacy of comprehensive traditional Chinese treatment, specifically auricular acupressure and manual acupuncture, in treating and preventing POI.

Trial registration

ClinicalTrials.gov, Identifier: ChiCTR2300075983, registered on September 21, 2023.

Caffeine intake enhances bowel recovery after colorectal surgery: a meta-analysis of randomized and non-randomized studies

Postoperative ileus (POI) after colorectal surgery is a major problem that affects both patient recovery and hospital costs highlighting the importance of preventive strategies. Therefore, we aimed to perform a systematic analysis of the effects of postoperative caffeine consumption on bowel recovery and surgical morbidity after colorectal surgery. A comprehensive literature search was conducted through September 2023 for randomized and non-randomized trials comparing the effect of caffeinated versus non-caffeinated drinks on POI by evaluating bowel movement resumption, time to first flatus and solid food intake, and length of hospital stay (LOS). Secondary outcome analysis included postoperative morbidity in both groups. After data extraction and inclusion in a meta-analysis, odds ratios (ORs) for dichotomous variables and standardized mean differences (SMDs) for continuous outcomes with 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed in cases of substantial heterogeneity. Six randomized and two non-randomized trials with a total of 610 patients were included in the meta-analysis. Caffeine intake significantly reduced time to first bowel movement [SMD -0.39, (95% CI -0.66 to -0.12), p = 0.005] and time to first solid food intake [SMD -0.41, (95% CI -0.79 to -0.04), p = 0.03] in elective laparoscopic colorectal surgery, while time to first flatus, LOS, and the secondary outcomes did not differ significantly. Postoperative caffeine consumption may be a reasonable strategy to prevent POI after elective colorectal surgery. However, larger randomized controlled trials (RCTs) with homogeneous study protocols, especially regarding the dosage form of caffeine and coffee, are needed.

Postoperative Ileus after Minimally Invasive Colorectal Surgery: A Summary of Current Strategies for Prevention and Management

BACKGROUND

Postoperative ileus (POI) is one of the most common postoperative complications after colorectal surgery and prolongs hospital stays. Minimally invasive surgery (MIS) has reduced POI, but it remains common. This review explores the current methods for preventing and managing POI after MIS.

SUMMARY

Preoperative interventions, including optimising nutrition, preoperative medicationn, and mechanical bowel preparation with oral antibiotics, may have a role in preventing POI. Transversus abdominis plane blocks and lidocaine could replace epidural analgesia in MIS. Fluid overload should be avoided; in some cases, goal-directed fluid therapy may aid in achieving this. Pharmacological agents, such as prucalopride and dexmedetomidine, could target mechanisms underlying POI. New strategies to stimulate vagal nerve activity may promote postoperative gastrointestinal motility. Preoperative bowel stimulation could potentially reduce POI following loop ileostomy closure. However, the evidence base for several interventions remains weak and requires further corroboration with robust studies.

KEY MESSAGES

Despite the increasing use of MIS, POI remains a major issue following colorectal surgery. Further strategies to prevent POI are rapidly emerging. Studies using standardised definitions and perioperative care will help validate these interventions and remove barriers to accurate meta-analysis. Future studies should focus on establishing the impact of these interventions on POI after MIS specifically.

Nomogram for predicting prolonged postoperative ileus after laparoscopic low anterior resection for rectal cancer

BACKGROUND

Prolonged postoperative ileus (PPOI) is a common complication after colorectal surgery that increases patient discomfort, hospital stay, and financial burden. However, predictive tools to assess the risk of PPOI in patients undergoing laparoscopic low anterior resection have not been developed. Thus, the purpose of this study was to develop a nomogram to predict PPOI after laparoscopic low anterior resection for rectal cancer.

METHODS

A total of 548 consecutive patients who underwent laparoscopic low anterior resection for mid-low rectal cancer at a single tertiary medical center were retrospectively enrolled between January 2019 and January 2023. Univariate and multivariate logistic regression analysis was performed to analyze potential predictors of PPOI. The nomogram was constructed using the filtered variables and internally verified by bootstrap resampling. Model performance was evaluated by receiver operating characteristic curve and calibration curve, and the clinical usefulness was evaluated by the decision curve.

RESULTS

Among 548 consecutive patients, 72 patients (13.1%) presented with PPOI. Multivariate logistic analysis showed that advantage age, hypoalbuminemia, high surgical difficulty, and postoperative use of opioid analgesic were independent prognostic factors for PPOI. These variables were used to construct the nomogram model to predict PPOI. Internal validation, conducted through bootstrap resampling, confirmed the great discrimination of the nomogram with an area under the curve of 0.738 (95%CI 0.736-0.741).

CONCLUSIONS

We created a novel nomogram for predicting PPOI after laparoscopic low anterior resection. This nomogram can assist surgeons in identifying patients at a heightened risk of PPOI.

The impact of preoperative sarcopenia on postoperative ileus following colorectal cancer surgery

PURPOSE

Sarcopenia is associated with poor short- and long-term patient outcomes following colorectal surgery. Despite postoperative ileus (POI) being a major complication following colorectal surgery, the predictive value of sarcopenia for POI is unclear. We assessed the association between sarcopenia and POI in patients with colorectal cancer.

METHODS

Elective colorectal cancer surgery patients were retrospectively included (2018-2022). The cross-sectional psoas area was calculated using preoperative staging imaging at the level of the 3rd lumbar vertebrae. Sarcopenia was determined using gender-specific cut-offs. The primary outcome POI was defined as not achieving GI-2 by day 4. Demographics, operative characteristics, and complications were compared via univariate and multivariate analyses.

RESULTS

Of 297 patients, 67 (22.6%) were sarcopenic. Patients with sarcopenia were older (median 74 (IQR 67-82) vs. 69 (58-76) years, p < 0.001) and had lower body mass index (median 24.4 (IQR 22.2-28.6) vs. 28.8 (24.9-31.9) kg/m2, p < 0.001). POI was significantly more prevalent in patients with sarcopenia (41.8% vs. 26.5%, p = 0.016). Overall rate of complications (85.1% vs. 68.3%, p = 0.007), Calvien-Dindo grade > 3 (13.4% vs. 10.0%, p = 0.026) and length of stay were increased in patients with sarcopenia (median 7 (IQR 5-12) vs. 6 (4-8) days, p = 0.013). Anastomotic leak rate was higher in patients with sarcopenia although the difference was not statistically significant (7.5% vs. 2.6%, p = 0.064). Multivariate analysis demonstrated sarcopenia (OR 2.0, 95% CI 1.1-3.8), male sex (OR 1.9, 95% CI 1.0-3.5), postoperative hypokalemia (OR 3.2, 95% CI 1.6-6.5) and increased opioid use (OR 2.4, 95% CI 1.3-4.3) were predictive of POI.

CONCLUSION

Sarcopenia demonstrates an association with POI. Future research towards truly identifying the predictive value of sarcopenia for postoperative complications could improve informed consent and operative planning for surgical patients.

Global cost of postoperative ileus following abdominal surgery: meta-analysis

BACKGROUND

Following abdominal surgery, postoperative ileus is a common complication significantly increasing patient morbidity and cost of hospital admission. This is the first systematic review aimed at determining the average global hospital cost per patient associated with postoperative ileus.

METHODS

A systematic search of electronic databases was performed from January 2000 to March 2023. Studies included compared patients undergoing abdominal surgery who developed postoperative ileus to those who did not, focusing on costing data. The primary outcome was the total cost of inpatient stay. Risk of bias was assessed using the Newcastle-Ottawa assessment tool. Summary meta-analysis was performed.

RESULTS

Of the 2071 studies identified, 88 papers were assessed for full eligibility. The systematic review included nine studies (2005-2022), investigating 1 860 889 patients undergoing general, colorectal, gynaecological and urological surgery. These studies showed significant variations in the definition of postoperative ileus. Six studies were eligible for meta-analysis showing an increase of €8233 (95 per cent c.i. (5176 to 11 290), P < 0.0001, I2 = 95.5 per cent) per patient with postoperative ileus resulting in a 66.3 per cent increase in total hospital costs (95 per cent c.i. (34.8 to 97.9), P < 0.0001, I2 = 98.4 per cent). However, there was significant bias between studies. Five colorectal-surgery-specific studies showed an increase of €7242 (95 per cent c.i. (4502 to 9983), P < 0.0001, I2 = 86.0 per cent) per patient with postoperative ileus resulting in a 57.3 per cent increase in total hospital costs (95 per cent c.i. (36.3 to 78.3), P < 0.0001, I2 = 85.7 per cent).

CONCLUSION

The global financial burden of postoperative ileus following abdominal surgery is significant. While further multicentre data using a uniform postoperative ileus definition would be useful, reducing the incidence and impact of postoperative ileus are a priority to mitigate healthcare-related costs, and improve patient outcomes.

Effect of remote ischemic preconditioning on postoperative gastrointestinal function in patients undergoing laparoscopic colorectal cancer resection

PURPOSE

Patients undergoing laparoscopic colorectal cancer resection have a high incidence of postoperative gastrointestinal dysfunction (POGD). Remote ischemic preconditioning (RIPC) is an organ protection measure. The study investigated the effect of RIPC on postoperative gastrointestinal function.

METHODS

In this single-center, prospective, double-blinded, randomized, parallel-controlled trial, 100 patients undergoing elective laparoscopic colorectal cancer resection were randomly assigned in a 1:1 ratio to receive RIPC or sham RIPC (control). Three cycles of 5-min ischemia/5-min reperfusion induced by a blood pressure cuff placed on the right upper arm served as RIPC stimulus. Patients were followed up continuously for 7 days after surgery. The I-FEED score was used to evaluate the patient's gastrointestinal function after the surgery. The primary outcome of the study was the I-FEED score on POD3. Secondary outcomes include the daily I-FEED scores, the highest I-FEED score, the incidence of POGD, the changes in I-FABP and the inflammatory markers (IL-6 and TNF-α), and the time to first postoperative flatus.

RESULTS

A total of 100 patients were enrolled in the study, of which 13 patients were excluded. Finally, 87 patients were included in the analysis, 44 patients in the RIPC group and 43 patients in the sham-RIPC group. Patients assigned to the RIPC group had a lower I-FEED score on POD3 compared with the sham-RIPC group (mean difference 0.86; 95% CI: 0.06 to 1.65; P = 0.035). And patients in the RIPC group were also associated with a lower I-FEED score on POD4 vs the sham-RIPC group (mean difference 0.81; 95% CI: 0.03 to 1.60; P = 0.043). Compared with the sham-RIPC group, the incidence of POGD within 7 days after surgery was lower in the RIPC group (P = 0.040). At T₁, T₂, and T₃ time points, inflammatory factors and I-FABP were considerably less in the RIPC group compared to the sham-RIPC group. The time to the first flatus and the first feces was similar in both groups.

CONCLUSION

RIPC reduced I-FEED scores, decreased the incidence of postoperative gastrointestinal dysfunction, and lowered concentrations of I-FABP and inflammatory factors.

Effect of neuromuscular reversal with neostigmine/glycopyrrolate versus sugammadex on postoperative ileus following colorectal surgery

BACKGROUND

Postoperative ileus (POI) is a common complication following colorectal surgery and is mediated in part by the cholinergic anti-inflammatory pathway (CAIP). Neostigmine (acetylcholinesterase inhibitor), co-administered with glycopyrrolate, is frequently given for neuromuscular reversal before tracheal extubation and modulates the CAIP. An alternative reversal agent, sugammadex (selective rocuronium or vecuronium binder), acts independently from the CAIP. The aim of our study was to assess the impact of neuromuscular reversal agents used during anaesthesia on gastrointestinal recovery.

METHODS

Three hundred thirty-five patients undergoing elective colorectal surgery at the Royal Adelaide Hospital between January 2019 and December 2021 were retrospectively included. The primary outcome was GI-2, a validated composite measure of time to diet tolerance and passage of stool. Demographics, 30-day complications and length of stay were collected. Univariate and multivariate analyses were performed.

RESULTS

Two hundred twenty-four (66.9%) patients (129 [57.6%] males and 95 [42.4%] females, median age 64 [19-90] years) received neostigmine/glycopyrrolate and 111 (33.1%) received sugammadex (62 [55.9%] males and 49 [44.1%] females, median age 67 [18-94] years). Sugammadex patients achieved GI-2 sooner after surgery (median 3 (0-10) vs. 3 (0-12) days, p = 0.036), and reduced time to first stool (median 2 (0-10) vs. 3 (0-12) days, p = 0.035). Rates of POI, complications and length of stay were similar. On univariate analysis, POI was associated with smoking history, previous abdominal surgery, colostomy formation, increased opioid use and postoperative hypokalaemia (p < 0.05). POI was associated with increased complications, including anastomotic leak and prolonged hospital stay (p < 0.001). On multivariate analysis, neostigmine, bowel anastomoses and increased postoperative opioid use (p < 0.05) remained predictive of time to GI-2.

CONCLUSIONS

Patients who received sugammadex had a reduced time to achieving first stool and GI-2. Neostigmine use, bowel anastomoses and postoperative opioid use were associated with delayed time to achieving GI-2.

Nomogram for prediction of prolonged postoperative ileus after colorectal resection

BACKGROUND

Prolonged postoperative ileus (PPOI) is a major complication in patients undergoing colorectal resection. The aim of this study was to analyze the risk factors contributing to PPOI, and to develop an effective nomogram to determine the risks of this population.

METHODS

A total of 1,254 patients with colorectal cancer who underwent radical colorectal resection at Fujian Cancer Hospital from March 2016 to August 2021 were enrolled as a training cohort in this study. Univariate analysis and multivariate logistic regressions were performed to determine the correlation between PPOI and clinicopathological characteristics. A nomogram predicting the incidence of PPOI was constructed. The cohort of 153 patients from Fujian Provincial Hospital were enrolled as a validation cohort. Internal and external validations were used to evaluate the prediction ability by area under the receiver operating characteristic curve (AUC) and a calibration plot.

RESULTS

In the training cohort, 128 patients (10.2%) had PPOI after colorectal resection. The independent predictive factors of PPOI were identified, and included gender, age, surgical approach and intraoperative fluid overload. The AUC of nomogram were 0.779 (95% CI: 0.736-0.822) and 0.791 (95%CI: 0.677-0.905) in the training and validation cohort, respectively. The two cohorts of calibration plots showed a good consistency between nomogram prediction and actual observation.

CONCLUSIONS

A highly accurate nomogram was developed and validated in this study, which can be used to provide individual prediction of PPOI in patients after colorectal resection, and this predictive power can potentially assist surgeons to make the optimal treatment decisions.

North American multicentre evaluation of a same-day discharge protocol for minimally invasive colorectal surgery using mHealth or telephone remote post-discharge monitoring

BACKGROUND

Same-day discharge (SDD) after colectomy is feasible but requires effective post-discharge remote follow-up. Previous studies have used in-person home visits or a mobile health (mHealth) phone app, but the use of simple telephone calls for remote follow-up has not yet been studied. Therefore, the objective of this study was to compare outcomes after SDD for minimally invasive colectomy using mHealth or telephone remote post-discharge follow-up.

METHODS

A prospective cohort study was undertaken at two university-affiliated colorectal referral institutions from 02/2020 to 05/2021. Adult patients without significant comorbidities undergoing elective minimally invasive colectomy. Patients were discharged on the day of surgery based on set criteria. Post-discharge remote follow-up was performed using a mHealth app at site 1 and scheduled telephone calls at site 2 up to postoperative day (POD) 7. The main outcome for this study was the success rate of SDD, defined as discharge on POD0 without emergency department (ED) visit or readmission within the first 3 days.

RESULTS

A total of 105 patients were recruited (site 1, n = 70; site 2, n = 35). Overall, 75% of patients were discharged on POD0 (site 1 81% vs. site 2 63%, p = 0.038), of which only two patients required an ED visit within the first 3 days, leading to an overall success rate of 73% (site 1 80% vs. site 2 60%, p = 0.029). The incidence of 30-day complications (16% vs. 20%, p = 0.583), ED visits (11% vs. 11%, p = 1.00), and readmissions (9% vs. 14%, p = 0.367) were similar between the two sites. There was only one patient at each study site that went to the ED without instructions through remote follow-up.

CONCLUSIONS

A high proportion of patients planned for SDD were discharged on POD0 with few patients requiring an early unplanned ED visit. These results were similar with an mHealth app or telephone calls for post-discharge remote follow-ups, suggesting that SDD is feasible regardless of the method of post-discharge remote follow-up.

Tolerating clear fluids diet on postoperative day 0 predicts early recovery of gastrointestinal function after laparoscopic colectomy

INTRODUCTION

A high proportion of colorectal surgery patients within an enhanced recovery pathway (ERP) do not experience complications but remain hospitalized mainly waiting for gastrointestinal (GI) recovery. Accurate identification of these patients may allow discharge prior to the return of GI function. Therefore, the objective of this study is to determine if tolerating clear fluid (CF) on postoperative day (POD) 0 was associated with uncomplicated return of GI function after laparoscopic colorectal surgery.

METHODS

Pooled data from three prospective studies from a single specialist colorectal referral center were analyzed (2013-2019). The present study included adult patients that underwent elective laparoscopic colectomy without stoma. Postoperative GI symptoms were collected daily in all three datasets. The main exposure variable, whether CF diet was tolerated on POD0, was defined as patients drinking at least 300 mL of CF without any nausea, anti-emetics, or vomiting (CF+ vs CF-). The main outcome measure was time to GI-3 (tolerating solid diet and passage of gas or stools).

RESULTS

A total of 221 patients were included in this study, including 69% CF+ and 31% CF-. The groups were similar in age, gender, and comorbidities, but the CF- patients were more likely to have surgery for inflammatory bowel disease. CF+ patients had faster time to GI-3 (mean 1.6d (SD 0.7) vs. 2.3d (SD 1.5), p < 0.001). The CF+ group also experienced fewer complications (19% vs. 35%, p = 0.009), shorter mean LOS (mean 3.6d (SD 2.9) vs. 6.2d (SD 9.4), p = 0.002), and were more likely to be discharged by the target LOS (66% vs. 50%, p = 0.024).

CONCLUSION

Toleration of CF on POD0 was associated with faster return of GI function, fewer complications, and shorter LOS. This may be used as a criteria for potential discharge prior to full return of GI function after laparoscopic colectomy within an ERP.

Before-and-After Study of the First Four Years of the Enhanced Recovery after Surgery (ERAS®) Programme in Older Adults Undergoing Elective Colorectal Cancer Surgery

BACKGROUND

The aim of this study was to determine whether the inclusion of older patients undergoing elective colorectal cancer resection in the Enhanced Recovery After Surgery (ERAS^®) programme could improve clinical outcomes during hospital admission.

METHODS

A before-and-after study in ≥70-year-old patients electively admitted for colorectal cancer resection was designed. In total, 213 patients were included in the ERAS^® group, and 158 were included in the control group.

RESULTS

The average age was 77.9 years old (SD 5.31) and 57.14% of them were men, with a Charlson Index score of 3.42 (SD 3.32). The ERAS^® group presented a lower transfusion rate of 42 (19.7%), compared to 75 (47.5%) in the control group (p < 0.001). The crude odds ratio (OR) for transfusion was 0.27 (95% CI 0.17-0.43; p < 0.001), and the adjusted odds ratio was 0.26 (95% CI 0.14-0.48; p < 0.001). The ERAS^® group had a lower percentage of patients with moderate-severe malnutrition on admission, at 23.4% (37 patients) against 36.2% in the control group (42 patients) (p = 0.023), with an OR of 0.47 (95% CI 0.29-0.75; p < 0.002) and an adjusted OR of 0.48 (95% CI 0.29-0.78; p = 0.003). The number of patients who required admission to the intensive care unit (ICU) was also markedly lower: 54 from the ERAS^® group (25.4%) versus 71 from the control group (44.9%) (p < 0.001).

CONCLUSIONS

The inclusion of ≥70-year-old adults in the ERAS^® programme resulted in a decrease in transfusions, number of erythrocyte concentrates transfused, and number of ICU admissions, along with improved nutritional status.

Same day discharge following elective, minimally invasive, colorectal surgery : A review of enhanced recovery protocols and early outcomes by the SAGES Colorectal Surgical Committee with recommendations regarding patient selection, remote monitoring, and successful implementation

BACKGROUND

As enhanced recovery programs (ERPs) have continued to evolve, the length of hospitalization (LOS) following elective minimally invasive colorectal surgery has continued to decline. Further refinements in multimodal perioperative pain management strategies have resulted in reduced opioid consumption. The interest in ambulatory colectomy has dramatically accelerated during the COVID-19 pandemic. Severe restrictions in hospital capacity and fear of COVID transmission forced surgical teams to rethink strategies to further reduce length of inpatient stay.

METHODS

Members of the SAGES Colorectal Surgery Committee began reviewing the emergence of SDD protocols and early publications for SDD in 2019. The authors met at regular intervals during 2020-2022 period reviewing SDD protocols, safe patient selection criteria, surrogates for postoperative monitoring, and early outcomes.

RESULTS

Early experience with SDD protocols for elective, minimally invasive colorectal surgery suggests that SDD is feasible and safe in well-selected patients and procedures. SDD protocols are associated with reduced opioid use and prescribing. Patient perception and experience with SDD is favourable. For early adopters, SDD has been the natural evolution of well-developed ERPs. Like all ERPs, SDD begins in the office setting, identifying the correct patient and procedure, aligning goals and objectives, and the perioperative education of the patient and their supporting significant others. A thorough discussion with the patient regarding expected activity levels, oral intake, and pain control post operatively lays the foundation for a successful application of SDD programs. These observations may not apply to all patient populations, institutions, practice types, or within the scope of an existing ERP. However, if the underlying principles of SDD can be incorporated into an existing institutional ERP, it may further reduce the incidence of post operative ileus, prolonged LOS, and improve the effectiveness of oral analgesia for postoperative pain management and reduced opioid use and prescribing.

CONCLUSIONS

The SAGES Colorectal Surgery Committee has performed a comprehensive review of the early experience with SDD. This manuscript summarizes SDD early results and considerations for safe and stepwise implementation of SDD with a specific focus on ERP evolution, patient selection, remote monitoring, and other relevant considerations based on hospital settings and surgical practices.

A Single-Institution Analysis of Targeted Colorectal Surgery Enhanced Recovery Pathway Strategies That Decrease Readmissions

BACKGROUND

Decreasing readmissions is an important quality improvement strategy. Targeted interventions that effectively decrease readmissions have not been fully investigated and standardized.

OBJECTIVE

The purpose of this study was to assess the effectiveness of interventions designed to decrease readmissions after colorectal surgery.

DESIGN

This was a retrospective comparison of patients before and after the implementation of interventions.

SETTING

This study was conducted at a single institution dedicated enhanced recovery pathway colorectal surgery service.

PATIENTS

The study group received quality review interventions that were designed to decrease readmissions: preadmission class upgrades, a mobile phone app, a pharmacist-led pain management strategy, and an early postdischarge clinic. The control group was composed of enhanced recovery patients before the interventions. Propensity score weighting was used to adjust patient characteristics and predictors for imbalances.

MAIN OUTCOME MEASURE

The primary outcome was 30-day readmissions. Secondary outcomes included emergency department visits.

RESULTS

There were 1052 patients in the preintervention group and 668 patients in the postintervention group. After propensity score weighting, the postintervention cohort had a significantly lower readmission rate (9.98% vs 17.82%, p < 0.001) and emergency department visit rate (14.58% vs 23.15%, p < 0.001) than the preintervention group, and surgical site infection type I/II was significantly decreased as a readmission diagnosis (9.46% vs 2.43%, p = 0.043). Median time to readmission was 6 (interquartile 3-11) days in the preintervention group and 8 (3-17) days in the postintervention group (p = 0.21). Ileus, acute kidney injury, and surgical site infection type III were common reasons for readmissions and emergency department visits.

LIMITATIONS

A single-institution study may not be generalizable.

CONCLUSION

Readmission bundles composed of targeted interventions are associated with a decrease in readmissions and emergency department visits after enhanced recovery colorectal surgery. Bundle composition may be institution dependent. Further study and refinement of bundle components are required as next-step quality metric improvements. See Video Abstract at http://links.lww.com/DCR/B849.

ANLISIS EN UNA SOLA INSTITUCIN DE LAS CIRUGAS COLORECTALES CON VAS DE RECUPERACIN DIRIGIDA AUMENTADA QUE REDUCEN LOS REINGRESOS

ANTECEDENTES:La reducción de los reingresos es una importante estrategia de mejora de la calidad. Las intervenciones dirigidas que reducen eficazmente los reingresos no se han investigado ni estandarizado por completo.OBJETIVO:El propósito de este estudio fue evaluar la efectividad de las intervenciones diseñadas para disminuir los reingresos después de la cirugía colorrectal.DISEÑO:Comparación retrospectiva de pacientes antes y después de la implementación de las intervenciones.ESCENARIO:Una sola institución dedicada al Servicio de cirugía colorrectal con vías de recuperación dirigida aumentadaPACIENTES:El grupo de estudio recibió intervenciones de revisión de calidad que fueron diseñadas para disminuir los reingresos: actualizaciones de clases previas a la admisión, una aplicación para teléfono móvil, una estrategia de manejo del dolor dirigida por farmacéuticos y alta temprana de la clínica. El grupo de control estaba compuesto por pacientes con recuperación mejorada antes de las intervenciones. Se utilizó la ponderación del puntaje de propensión para ajustar las características del paciente y los predictores de los desequilibrios.PARÁMETRO DE RESULTADO PRINCIPAL:El resultado primario fueron los reingresos a los 30 días. Los resultados secundarios incluyeron visitas al servicio de urgencias.RESULTADOS:Hubo 1052 pacientes en el grupo de preintervención y 668 pacientes en el grupo de posintervención. Después de la ponderación del puntaje de propensión, la cohorte posterior a la intervención tuvo una tasa de reingreso significativamente menor (9,98% frente a 17,82%, p <0,001) y una tasa de visitas al servicio de urgencias (14,58% frente a 23,15%, p <0,001) que el grupo de preintervención y la infección del sitio quirúrgico tipo I / II se redujo significativamente como diagnóstico de reingreso (9,46% frente a 2,43%, p = 0,043). La mediana de tiempo hasta la readmisión fue de 6 [IQR 3, 11] días en el grupo de preintervención y de 8 [3, 17] días en el grupo de posintervención (p = 0,21). El íleo, la lesión renal aguda y la infección del sitio quirúrgico tipo III fueron motivos frecuentes de reingresos y visitas al servicio de urgencias.LIMITACIONES:El estudio de una sola institución puede no ser generalizable.CONCLUSIÓNES:Los paquetes de readmisión compuestos por intervenciones dirigidas se asocian con una disminución en las readmisiones y las visitas al departamento de emergencias después de una cirugía colorrectal con vías de recuperación dirigida aumentada. La composición del paquete puede depender de la institución. Se requieren más estudios y refinamientos de los componentes del paquete como siguiente paso de mejora de la métrica de calidad. Consulte Video Resumen en http://links.lww.com/DCR/B849. (Traducción-Dr Yolanda Colorado).

The Role of Inflammatory Mediators in the Development of Gastrointestinal Motility Disorders

Feeding intolerance and the development of ileus is a common complication affecting critically ill, surgical, and trauma patients, resulting in prolonged intensive care unit and hospital stays, increased infectious complications, a higher rate of hospital readmission, and higher medical care costs. Medical treatment for ileus is ineffective and many of the available prokinetic drugs have serious side effects that limit their use. Despite the large number of patients affected and the consequences of ileus, little progress has been made in identifying new drug targets for the treatment of ileus. Inflammatory mediators play a critical role in the development of ileus, but surprisingly little is known about the direct effects of inflammatory mediators on cells of the gastrointestinal tract, and many of the studies are conflicting. Understanding the effects of inflammatory cytokines/chemokines on the development of ileus will facilitate the early identification of patients who will develop ileus and the identification of new drug targets to treat ileus. Thus, herein, we review the published literature concerning the effects of inflammatory mediators on gastrointestinal motility.

A snapshot of intraoperative conditions to predict prolonged postoperative ileus after colorectal surgery

BACKGROUND

The cause of prolonged postoperative ileus (PPOI) is multifactorial. The influence of preoperative factors on PPOI has been well documented, but little is known about the impact of intraoperative conditions. The aim of this study was to investigate the influence of intraoperative factors on PPOI in patients undergoing colorectal surgery.

METHODS

The LekCheck study database of the Colorectal Unit at the Royal Adelaide Hospital was analysed. Per patient, over 60 data points were prospectively collected between March 2018 and July 2020. Intraoperative data were collected in theatre during a one-off snapshot measure. Univariate and multivariable logistic regression analyses were performed.

RESULTS

Data of 336 patients were included. The median age was 66 years and 58.3% were male. Ninety-three patients (27.7%) developed PPOI. Univariate analysis identified the following intraoperative variables as risk-factors of PPOI: greater volumes of intraoperative IV fluid administration (464 versus 415 mL/h for those without PPOI; p = 0.04), side-to-side anastomosis orientation (53.8 versus 41.2%; p = 0.04) and increased perioperative opioid use (6.73 versus 4.11 mg/kg morphine equivalents for patients with and without PPOI, respectively; p = 0.02). Upon multivariable analysis, increased perioperative opioid use remained significant (p = 0.05), as well as the preoperative factors anticoagulation use (p = 0.04) and higher levels of serum total protein (p = 0.02).

CONCLUSION

This study suggests that intraoperative factors may also contribute to the development of PPOI, but this could not be confirmed in the multivariate analysis. Further studies including larger patient numbers will be required to determine the impact of intraoperative conditions on the development of PPOI.

Comparison of prolonged postoperative ileus between laparoscopic right and left colectomy under enhanced recovery after surgery: a propensity score matching analysis

Background

There were differences in the recovery of bowel function and prolonged postoperative ileus (PPOI) between laparoscopic right colectomy (RC) and left colectomy (LC) under the guidance of enhanced recovery after surgery.

Methods

We selected 870 patients who underwent elective laparoscopic colectomy from June 2016 to December 2021, including 272 patients who had RC and 598 who had LC. According to 1:1 proportion for propensity score matching and correlation analysis, 247 patients who had RC and 247 who had LC were finally enrolled.

Results

The incidence of PPOI in all patients was 13.1%. Age, sex, smoking habit, preoperative serum albumin level, operation type, and operation time were the important independent risk factors based on multivariate logistic regression and correlation analysis for PPOI (p<0.05). Age, sex, body mass index, preoperative serum albumin level, operation time, and degree of differentiation between the two groups were significantly different before case matching (p<0.05). There were no statistically significant differences in baseline characteristics and preoperative biochemical parameters between the two groups after case matching (p>0.05). The incidence of PPOI in patients who had RC was 21.9%, while that in patients who had LC was 13.0%. The first flatus, first semi-liquid, and length of stay in LC patients were lower than those in RC patients (p<0.05).

Conclusion

The return of bowel function in LC was faster than that in RC, and the incidence of PPOI was relatively lower. Therefore, caution should be taken during the early feeding of patients who had laparoscopic RC.

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.

A systematic review of the literature assessing operative blood loss and postoperative outcomes after colorectal surgery

PURPOSE

There is no consensus in the literature regarding the association between operative blood loss and postoperative outcomes in colorectal surgery, despite evidence suggesting a link. Therefore, this systematic review assesses the association between operative blood loss, perioperative and long-term outcomes after colorectal surgery.

METHODS

A literature search of MEDLINE, EMBASE, Science Citation Index Expanded and Cochrane was performed to identify studies reporting on operative blood loss in colorectal surgery.

RESULTS

The review included forty-nine studies reporting on 61,312 participants, with a mean age ranging from 53.4 to 78.1 years. The included studies demonstrated that major operative blood loss was found to be a risk factor for mortality, anastomotic leak, presacral abscess, and postoperative ileus, leading to an increased duration of hospital stay. In the long term, the studies suggest that significant blood loss was an independent risk factor for future small bowel obstruction due to colorectal cancer recurrence and adhesions. Studies found that survival was significantly reduced, whilst the risk of colorectal cancer recurrence was increased. Reoperation and cancer-specific survival were not associated with major blood loss.

CONCLUSION

The results of this systematic review suggest that major operative blood loss increases the risk of perioperative adverse events and has short and long-term repercussions on postoperative outcomes. Laparoscopic and robotic surgery, vessel ligation technology and anaesthetic considerations are essential for reducing blood loss and improving outcomes. This review highlights the need for further high quality, prospective, multicentre trials with a greater number of participants, and accurate and standardised methods of measuring operative blood loss.

Prolonged postoperative ileus following right- versus left-sided colectomy: A systematic review and meta-analysis

AIM

Prolonged postoperative ileus (PPOI) is a common complication following colonic surgery, and is associated with longer hospital stay, greater risk of complications and substantial cost for patients and hospitals. Some reports have recently suggested that gastrointestinal (GI) recovery varies based on the side of resection (i.e., right-sided vs. left-sided colectomy). This systematic review and meta-analysis aimed to compare GI recovery by resection side.

METHODS

The MEDLINE, Embase, Cochrane Library and CENTRAL databases were systematically searched for articles reporting GI recovery outcomes in adults undergoing elective right- versus left-sided colectomy (excluding with ileostomy) of any surgical approach. The primary outcome was PPOI, and secondary outcomes included time to first passage of flatus, stool and tolerance of solid diet, and postoperative complications. Subgroup analyses of laparoscopic procedures and cohorts without inflammatory bowel disease and sensitivity analysis of adjusted multivariate results were also performed.

RESULTS

Nine studies were identified, of which seven were included in the meta-analysis, comprising 29 068 colectomies (14 581 right-sided; 14 487 left-sided). PPOI was heterogeneously defined and was significantly more likely following right-sided compared to left-sided colectomy regardless of the surgical approach (OR 1.78, 95% CI 1.32-2.39; P < 0.01; I²  = 51%), as well as on subgroup analyses and adjusted multivariate meta-analysis. Secondary outcomes were reported in only a few small studies; hence meta-analysis did not produce reliable results.

CONCLUSION

Based on heterogeneous definitions, consistently higher rates of PPOI were observed following right- versus left-sided colectomy. These differences are currently unexplained and highlight the need for further research into the pathophysiology of ileus.

Trajectory of gastrointestinal function after laparoscopic colorectal surgery within an enhanced recovery pathway

BACKGROUND

Early identification of colorectal surgery patients predicted to have uneventful gastrointestinal recovery may allow for early discharge. Our objective was to identify trajectories of gastrointestinal recovery within a colorectal surgery enhanced recovery pathway.

METHODS

Data from 2 prospective studies enrolling adult patients undergoing elective laparoscopic colorectal resection at a specialist colorectal referral center were analyzed (2013-2019). All patients were managed according to a mature enhanced recovery pathway with a 3-day target length of stay. Postoperative gastrointestinal symptoms were collected daily and expressed using the validated I-FEED score. Latent-class growth curve (trajectory) analysis was used to identify different I-FEED trajectories over the first 3 postoperative days.

RESULTS

A total of 192 patients were analyzed. Trajectory analysis identified 3 distinct trajectories: trajectory 1 had no gastrointestinal symptoms (41%); trajectory 2 had mild early symptoms with improvement over time (48%); and trajectory 3 had gastrointestinal symptoms that significantly worsened between postoperative days 1 and 2 (11%). I-FEED score ≤1 on postoperative day 1 predicted trajectory 1. Trajectory 1 had the best clinical outcomes, whereas trajectory 3 had the worst.

CONCLUSION

I-FEED trajectory over postoperative days 1-3 was associated with clinical outcomes and may be used to predict gastrointestinal recovery. Findings from this study may inform clinical decision making regarding early hospital discharge within colorectal enhanced recovery pathways.

Randomized Controlled Trial: Perioperative Dexamethasone Reduces Excessive Postoperative Inflammatory Response and Ileus After Surgery for Inflammatory Bowel Disease

BACKGROUND

An excessive postoperative inflammatory response is common after surgery for inflammatory bowel disease (IBD) and may be associated with an increased incidence of postoperative ileus. This study assessed the role of perioperative dexamethasone in postoperative ileus after IBD surgery.

METHOD

Patients undergoing elective IBD surgery were randomized to either an intravenous 8-mg dose of dexamethasone (n = 151) or placebo (n = 151) upon induction of anesthesia. The primary outcome was the incidence of prolonged postoperative ileus. Secondary outcomes included incidence of reported nausea or vomiting, time to first passage of flatus and stool, GI-2 recovery, postoperative pain, length of stay, and surgical complications.

RESULTS

An intention-to-treat analysis revealed that patients who received dexamethasone exhibited a lower incidence of prolonged postoperative ileus (22.5% vs 38.4%; P = 0.003), shorter time to first passage of stool (28 vs 48 h, P < 0.001), GI-2 recovery (72 vs 120 h; P < 0.001), reduced postoperative length of stay (9.0 vs 10.0 d; P = 0.002), and less postoperative pain (P < 0.05) compared with controls. Moreover, there were no significant differences in postoperative nausea or vomiting (P = 0.531), major postoperative complications (P = 0.165), or surgical site infections (P = 0.337) between the groups. A benefit was only observed in patients with Crohn's disease, restored bowel continuity, colon/rectal resections, and those who underwent open operations.

CONCLUSION

A single, intravenous 8-mg dose of dexamethasone upon induction of anesthesia reduced the incidence of prolonged postoperative ileus, the intensity of postoperative pain, and shortened the postoperative length of stay for IBD patients undergoing elective surgery. ClinicalTrials.gov: NCT03456752.

Targets for Intervention? Preoperative Predictors of Postoperative Ileus After Colorectal Surgery in an Enhanced Recovery Protocol

BACKGROUND

Postoperative ileus occurs in up to 30% of colorectal surgery patients and is associated with increased length of stay, costs, and morbidity. While Enhanced Recovery Protocols seek to accelerate postoperative recovery, data on modifiable preoperative factors associated with postoperative ileus in this setting are limited. We aimed to identify preoperative predictors of postoperative ileus following colorectal surgery in Enhanced Recovery Protocols, to determine new intervention targets.

METHODS

We performed a retrospective single-center cohort study of patients ≥ 18 years old who underwent colorectal surgery via Enhanced Recovery Protocols (7/2015-7/2017). Postoperative ileus was defined as nasogastric tube insertion postoperatively or nil-per-os by postoperative day 4. Preoperative risk factors including comorbidities and medication use were identified using multivariable stepwise logistic regression.

RESULTS

Of 530 patients, 14.9% developed postoperative ileus. On univariate analysis of perioperative and postoperative factors, postoperative ileus patients had increased psychiatric illness, antidepressant and antipsychotic use, American Society of Anesthesiologists classification, ileostomy creation, postoperative opioid use, complications, surgery duration, and length of stay (p < 0.05). Multivariable logistic regression model for preoperative factors identified psychiatric illness, preoperative antipsychotic use, and American Society of Anesthesiologists classification ≥ 3 as significant predictors of postoperative ileus (p < 0.05).

DISCUSSION

Postoperative ileus remains a common complication following colorectal surgery under Enhanced Recovery Protocols. Patients with pre-existing psychiatric comorbidities and preoperative antipsychotic use may be a previously overlooked cohort at increased risk for postoperative ileus. Additional research and preoperative interventions within Enhanced Recovery Protocols to reduce postoperative ileus for this higher-risk population are needed.

Role of Enhanced Recovery Program for Colorectal Cancer Patients: National Cancer Institute Experience

Enhanced recovery program (ERP) was introduced in patients scheduled for colorectal surgical procedures to enhance gastrointestinal recovery and shorten their hospital stay. This study aims to evaluate the role of ERP in colorectal cancer patients. A prospective cohort study performed at National Cancer Institute-Cairo University including 50 patients with colorectal cancer treated between October 2016 and May 2017. They were divided in 2 equal groups: study group (ERP group) and control group (conventional protocol group). Incidence of postoperative morbidity was greater in the control group compared to the study group. Only the incidence of paralytic ileus was greater in the study group. The study group had a statistically significant hospital stay length compared to the control group. ERP was associated with lower incidence of postoperative morbidity excluding incidence of paralytic ileus; also, it was associated with a shorter hospital stay.

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.

Risk factors for upper and lower type prolonged postoperative ileus following surgery for Crohn's disease

PURPOSE

Prolonged postoperative ileus (PPOI) is common after bowel resections, especially in Crohn's disease (CD). The pathophysiology of PPOI is not fully understood. PPOI could affect only the upper or lower gastrointestinal (GI) tract. The aim of this study was to assess risk factors for diverse types of PPOI, particularly to differentiate PPOI of upper and lower GI tract.

METHODS

A retrospective analysis of 163 patients with CD undergoing ileocecal resection from 2015 to 2020 in a single center was performed. PPOI of the upper GI tract was predefined as the presence of vomiting or use of nasogastric tube longer than the third postoperative day. Lower PPOI was predefined as the absence of defecation for more than three days. Independent risk factors were identified by multivariable logistic regression analysis.

RESULTS

Overall incidence of PPOI was 42.7%. PPOI of the upper GI tract was observed in 30.7% and lower PPOI in 20.9% of patients. Independent risk factors for upper PPOI included older age, surgery by a resident surgeon, hand-sewn anastomosis, prolonged opioid analgesia, and reoperation, while for lower PPOI included BMI ≤ 25 kg/m², preoperative anemia, and absence of ileostomy.

CONCLUSION

This study identified different risk factors for upper and lower PPOI after ileocecal resection in patients with CD. A differentiated upper/lower type approach should be considered in future research and clinical practice. High-risk patients for each type of PPOI should be closely monitored, and modifiable risk factors, such as preoperative anemia and opioids, should be avoided if possible.

Proposition of a simple binary grading of estimated blood loss during colon surgery

PURPOSE

Intraoperative estimated blood loss (EBL) is often reported in nearly all surgical papers; however, there is no consensus regarding its measurement. The aim of this study was to determine whether EBL (ml) is as reliable and reproducible in predicting complications as a simple binary grading of EBL.

METHODS

All consecutive patients undergoing colectomies between January 2015 and December 2018 were included. EBL was assessed prospectively by the surgeon and anaesthesiologist in ml and with a binary scale: bleeding "as usual" versus "more than usual" by the surgeon. Differences between pre- and post-operative haemoglobin levels (ΔHb g/dl) were correlated to EBL. Blood loss impact on 30-day postoperative morbidity was analysed.

RESULTS

A total of 270 patients were included, with a mean age of 65 years (SD 17). Mean EBL documented by surgeons correlated to EBL by anaesthesiologists (79.5 ml, SD 99 vs. 84.5 ml, SD 118, ϱ = 0.926, p < 0.001). Surgeons and anaesthesiologists' EBL correlated also with ΔHb (ϱ = - 0.273, p = 0.01 and ϱ = - 0.344, p = 0.01, respectively). Patient with surgeon EBL ≥ 250 ml or graded as "more than usual" bleeding had significantly more severe complications (8% vs. 20%, p = 0.02 and 8% vs. 27%, p = 0.001, respectively).

CONCLUSION

Anaesthesiologist and surgeon's EBL correlated with ΔHb. Simple grading of blood loss as "usual" and "more than usual" predicted severe complications and higher mortality rates. This simple binary grading of blood loss in colon surgery could be an alternative to the estimation of blood loss in ml as it is easy to apply but needs to be validated externally.

Management of perforated diverticulitis with generalized peritonitis. A multidisciplinary review and position paper

Perforated diverticulitis is an emergent clinical condition and its management is challenging and still debated. The aim of this position paper was to critically review the available evidence on the management of perforated diverticulitis and generalized peritonitis in order to provide evidence-based suggestions for a management strategy. Four Italian scientific societies (SICCR, SICUT, SIRM, AIGO), selected experts who identified 5 clinically relevant topics in the management of perforated diverticulitis with generalized peritonitis that would benefit from a multidisciplinary review. The following 5 issues were tackled: 1) Criteria to decide between conservative and surgical treatment in case of perforated diverticulitis with peritonitis; 2) Criteria or scoring system to choose the most appropriate surgical option when diffuse peritonitis is confirmed 3); The appropriate surgical procedure in hemodynamically stable or stabilized patients with diffuse peritonitis; 4) The appropriate surgical procedure for patients with generalized peritonitis and septic shock and 5) Optimal medical therapy in patients with generalized peritonitis from diverticular perforation before and after surgery. In perforated diverticulitis surgery is indicated in case of diffuse peritonitis or failure of conservative management and the decision to operate is not based on the presence of extraluminal air. If diffuse peritonitis is confirmed the choice of surgical technique is based on intraoperative findings and the presence or risk of severe septic shock. Further prognostic factors to consider are physiological derangement, age, comorbidities, and immune status. In hemodynamically stable patients, emergency laparoscopy has benefits over open surgery. Options include resection and anastomosis, Hartmann’s procedure or laparoscopic lavage. In generalized peritonitis with septic shock, an open surgical approach is preferred. Non-restorative resection and/or damage control surgery appear to be the only viable options, depending on the severity of hemodynamic instability. Multidisciplinary medical management should be applied with the main aims of controlling infection, relieving postoperative pain and preventing and/or treating postoperative ileus. In conclusion, the complexity and diversity of patients with diverticular perforation and diffuse peritonitis requires a personalized strategy, involving a thorough classification of physiological derangement, staging of intra-abdominal infection and choice of the most appropriate surgical procedure.

Intracorporeal versus extracorporeal anastomosis for right colectomy does not affect gastrointestinal recovery within an enhanced recovery after surgery program

INTRODUCTION

Delayed gastrointestinal (GI) recovery remains a significant morbidity after colorectal surgery. Intracorporeal anastomosis for right colectomy may hasten GI recovery. Therefore, the objective of this study was to determine the effect of intracorporeal versus extracorporeal anastomosis on GI recovery after elective laparoscopic right colectomy within an established ERAS program.

METHODS

Adult patients undergoing elective laparoscopic right colectomy at a single high-volume institution from 07/2014 to 12/2018 were reviewed. Patients were divided into two groups: intracorporeal (IC) and extracorporeal (EC). The primary outcome was time to GI-3 defined as days to tolerance of solid diet and first flatus/bowel movement. Prolonged postoperative ileus (PPOI) was defined as GI-3 not met by postoperative day 4. Secondary outcomes were length of stay (LOS) and overall 30-day complications. Sensitivity analysis was performed using coarsened exact matching to account for unmeasured confounding. Multiple regression was performed using a Cox proportional hazard model to identify predictors of GI recovery.

RESULTS

A total of 346 patients were reviewed, of which 226 were included (71IC, 155EC). Patient characteristics were well balanced between groups: mean age was 64.9 years (SD 15.9), BMI was 26.3 (SD 5.7), 38.1% of patients had ASA ≥ 3, and 78.3% underwent surgery for neoplasms. IC anastomosis was associated with longer operative duration (165 min (SD 40); 144 min (SD 48), p = 0.002). There was no difference in the median time to GI-3 (IC 2 days [IQR1-2]; EC 2 days [IQR2-3], p = 0.135). The incidence of PPOI (IC 8.5%; EC 10.3%, p = 0.659), superficial SSI (4.2% vs. 5.8%, p = 0.757), deep SSI (2.8% vs. 5.2%, p = 0.729), and median LOS (3 days [IQR 2-4] vs. 3 [IQR 3-5], p = 0.059) were also similar. On multivariate analysis, IC anastomosis did not independently predict faster GI recovery (HR 0.98, 95% CI 0.71-1.34). Similar results were observed in the matched cohort (185 patients (61IC, 124EC)).

CONCLUSION

In this study, IC anastomosis was not associated with faster GI recovery or reduced complication rate compared to EC anastomosis. Longer term studies may be required to determine the potential benefits of IC anastomosis.

Gastrointestinal motility has more of an impact on postoperative recovery than you might expect

PURPOSE

While patient's reported autonomy (PRA) may help the physician to adapt the day of discharge, the link between postoperative ileus and length of stay and PRA is not known. The aim of this study was to evaluate the evolution of the PRA score during the postoperative period and to determine the factors possibly influencing such an evolution.

METHODS

This retrospective study on a prospective database took place in a single centre over 14 months. PRA was defined by the by using part I of the Groningen Activity Restriction Scale known as activity of daily life [from 9 (best) to 45 (worst)].

RESULTS

Among the 101 patients operated on for elective or emergent colorectal surgery, 80% of the patients had recovered their preoperative PRA (±5 points) before discharge and maintained their PRA during the 2 days preceding discharge. While PRA was significantly decreased by surgery (P<0.0001), each postoperative day allowed for its progressive recovery. Interestingly, the day of recovery of GI transit was associated with a significant increase of PRA (-6.96 points, P<0.0001). Despite high variability of baseline autonomy level, patients presented very similar recovery processes, which were represented by very low slope variability in the linear mixed model. Laparoscopy reduced the decrease of postoperative PRA (P=0.03) while ASA score>2 increased PRA (P=0.03). Age, emergency surgery and the occurrence of postoperative morbidity did not affect postoperative autonomy. Finally, enhanced recovery programs (ERP) tended to improve postoperative autonomy recovery (P=0.09).

CONCLUSION

PRA may be used as a means of optimising a patient's day of discharge following colorectal surgery.