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

Leveraging Nursing Assessment for Early Identification of Post Operative Gastrointestinal Dysfunction (POGD) in Patients Undergoing Colorectal Surgery

Background: Postoperative gastrointestinal dysfunction (POGD) remains a common morbidity after gastrointestinal surgery. POGD is associated with delayed hospital recovery, increased length of stay, poor patient satisfaction and experience, and increased economic hardship. The I-FEED scoring system was created by a group of experts to address the lack of a consistent objective definition of POGD. However, the I-FEED tool needs clinical validation before it can be adopted into clinical practice. The scope of this phase 1 Quality Improvement initiative involves the feasibility of implementing percussion into the nursing workflow without additional burden. Methods: All gastrointestinal/colorectal surgical unit registered nurses underwent comprehensive training in abdominal percussion. This involved understanding the technique, its application in postoperative gastrointestinal dysfunction assessment, and its integration into the existing nursing documentation in the Electronic Health Record (EHR). After six months of education and practice, a six-question survey was sent to all inpatient GI surgical unit nurses about incorporating the percussion assessment into their routine workflow and documentation. Results: Responses were received from 91% of day-shift nurses and 76% of night-shift registered nurses. Overall, 95% of the nurses were confident in completing the abdominal percussion during their daily assessment. Conclusion: Nurses' effective use of the I-FEED tool may help improve patient outcomes after surgery. The tool could also be an effective instrument for the early identification of postoperative gastrointestinal dysfunction (POGD) in surgical patients.

Risk factors for post-operative ileus in patients with anterior resection for rectal cancer. A single center cohort

BACKGROUND

Postoperative ileus (POI) is a major cause of morbidity in patients undergoing colorectal surgery. The aim of our study was to evaluate potential risk factors for POI in cases with anterior resection for rectal cancer.

METHODS

A retrospective cohort study was performed on 136 patients who underwent open anterior resection for rectal cancer between 2004 and 2018 at a single tertiary referral center. POI was defined as reinsertion of nasogastric tube or nil per os by postoperative day 4 and/or administration of neostigmine postoperatively. Uni- and multivariate analysis was performed to identify potential risk factors for POI.

RESULTS

POI was observed in 18 patients (13.2%). Epidural anesthesia, type of ostomy, and history of abdominal surgery were not found to be related with POI. Advanced age was a statistically significant risk factor both in the uni- and in the multivariate analyses. An increase in age by 1 year was found to increase the odds of POI by 5% [95%CI: 0.4%-9.7%; p = 0.032].

CONCLUSION

Increased age was identified as a non-modifiable, patient-related risk factor for POI after anterior resection for rectal cancer. This finding is of particular importance as it turns the focus on the elderly patient and underlines the need for close clinical observation of this subgroup and liberal use of preventive and/or therapeutic measures postoperatively.

Baseline assessment of enhanced recovery after pediatric surgery in mainland China

BACKGROUND

Enhanced recovery after surgery (ERAS) is a clinical pathway that optimizes perioperative management based on evidence-based medicine. ERAS has been gradually introduced to pediatric surgery in recent years. However, there are limited reports on its overall implementation. We aimed to determine the implementation of ERAS in patients who received pediatric surgery in mainland China.

METHODS

We designed a questionnaire involving 17 key ERAS elements and sent the questionnaire to 66 chiefs of pediatric surgery distributed throughout 31 provinces in mainland China to obtain a baseline assessment of the assimilation of ERAS protocols in the care of congenital biliary dilatation (CBD).

RESULTS

A total of 66 questionnaires were collected. The range of elements implemented at participating centers was 4-16, with a mean of 10.23. The least commonly practiced elements were administration of non-opioid preoperative analgesia (6 centers, 9.09%), prevention of postoperative nausea and vomiting [PONV] (9 centers, 13.64%), and postoperative pain management (26 centers, 39.39%).

CONCLUSIONS

The implementation of elements differed from center to center. Measures relying primarily on anesthesiologists had lower execution. The adherence to ERAS elements was often inhibited by a lack of institutional support, poor knowledge of ERAS protocols, and difficulties in coordinating multidisciplinary care, as well intransigence in changing surgical practices out of fear of liability for poor outcomes.