Anesthesia for colorectal surgery

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.

Colorectal Surgery in Critically Unwell Patients: A Multidisciplinary Approach

A proportion of patients require critical care support following elective or urgent colorectal procedures. Similarly, critically ill patients in intensive care units may also need colorectal surgery on occasions. This patient population is increasing in some jurisdictions given an aging population and increasing societal expectations. As such, this population often includes elderly, frail patients or patients with significant comorbidities. Careful stratification of operative risks including the need for prolonged intensive care support should be part of the consenting process. In high-risk patients, especially in setting of unplanned surgery, treatment goals should be clearly defined, and appropriate ceiling of care should be established to minimize care that is not in the best interest of the patient. In this article we describe approaches to critically unwell patients requiring colorectal surgery and how a multidisciplinary approach with proactive intensive care involvement can help achieve the best outcomes for these patients.

Oral Supplementation with Sucrosomial Ferric Pyrophosphate Plus L-Ascorbic Acid to Ameliorate the Martial Status: A Randomized Controlled Trial

Altered martial indices before orthopedic surgery are associated with higher rates of complications and greatly affect the patient’s functional ability. Oral supplements can optimize the preoperative martial status, with clinical efficacy and the patient’s tolerability being highly dependent on the pharmaceutical formula. Patients undergoing elective hip/knee arthroplasty were randomized to be supplemented with a 30-day oral therapy of sucrosomial ferric pyrophosphate plus L-ascorbic acid. The tolerability was 2.7% among treated patients. Adjustments for confounding factors, such as iron absorption influencers, showed a relevant response limited to older patients (≥ 65 years old), whose uncharacterized Hb loss was averted upon treatment with iron formula. Older patients with no support lost −2.8 ± 5.1%, while the intervention group gained +0.7 ± 4.6% of circulating hemoglobin from baseline (p = 0.019). Gastrointestinal diseases, medications, and possible dietary factors could affect the efficacy of iron supplements. Future opportunities may consider to couple ferric pyrophosphate with other nutrients, to pay attention in avoiding absorption disruptors, or to implement interventions to obtain an earlier martial status optimization at the population level.

Does adherence to perioperative enhanced recovery pathway elements influence patient-reported recovery following colorectal resection?

INTRODUCTION

Patient-reported outcome measures (PROMs) are pivotal to promote patient-centered perioperative care. Adherence to enhanced recovery programs (ERPs) is associated with improved clinical outcomes (i.e., morbidity, length of stay), but the impact of adherence on PROMs is uncertain. The objective of this study was to evaluate the extent to which adherence to an ERP for colorectal surgery is associated with postoperative recovery as assessed using PROMs.

METHODS AND PROCEDURES

100 patients were included [median age 63 (IQR 50-71) years, 81 laparoscopic, 37 rectal surgery]. Overall adherence to the ERP and adherence to specific ERP elements were analyzed. Adjusted linear regression was used to evaluate the association of adherence with PROMs assessing early recovery [Abdominal surgery impact scale (ASIS) and Multidimensional fatigue inventory (MFI) on POD2] and late recovery (Duke Activity Status Index, RAND-36 Physical and Mental Summary Scores, Life-Space Mobility Assessment at 4 weeks after surgery). Missing data were addressed using multiple imputations.

RESULTS

Median adherence to the ERP was 80% (16/20 elements, IQR 70-90%). Overall adherence was associated with ASIS scores on POD2 (4% increase per additional element, 95% CI 1-8%; p = 0.018). When specific ERP elements were analyzed, ASIS scores were associated with adherence to PONV prophylaxis (34% increase, 95% CI 5-63%; p = 0.023) and early solid food diet (20% increase, 95% CI 5-35%; p = 0.009). MFI General fatigue and MFI Mental fatigue scores on POD2 were associated with adherence to PONV prophylaxis (36% decrease, 95% CI - 64 to - 8%, p = 0.014 and 22% decrease, 95% CI - 44 to - 8%, p = 0.042). Overall adherence and adherence to specific elements were not associated with PROMs at 4 weeks after surgery.

CONCLUSION

Our findings suggest that, from the perspective of patients, adherence to an ERP for colorectal surgery impacts early, but not late postoperative recovery. This result may reflect the lack of PROMs able to validly measure postoperative recovery beyond hospital discharge.

Transversus abdominis plane block reduces remifentanil and propofol consumption, evaluated by closed-loop titration guided by bispectral index

The present prospective, randomized, double-blind study aimed to determine the impact of transversus abdominis plane (TAP) block on propofol and remifentanil consumption, when administered by closed-loop titration guided by processed electroencephalography, i.e., bispectral index (BIS) values. Following institutional review board approval, 60 patients were scheduled for laparoscopic colectomy under general anesthesia. Patients were randomly assigned to receive bilateral TAP block with 20 ml 0.375% ropivacaine (TAP group) or 20 ml 0.9% saline [control (CON) group]. General anesthesia was maintained with propofol and remifentanil administration using closed-loop titration guided by BIS values. The primary outcome was perioperative propofol and remifentanil consumption. The secondary outcomes were hypertensive or hypotensive events requiring treatment, recovery time in PACU and time to first rescue analgesia following surgery. A total of 58 patients participated in the present study. At similar depths of anesthesia, as measured by BIS during the maintenance phase (45–55), patients who received TAP blocks required less propofol (4.2±1.3 vs. 5.5±1.6 mg/kg/h; P<0.001) and remifentanil (0.16±0.05 vs. 0.21±0.05 µg/kg/min; P<0.001). Time to extubation was significantly shorter in the TAP group (9.8±3.2 min) than in the CON group (14.2±4.9 min) (P<0.05). The requirement to treat hemodynamic change was also significantly lower (P<0.05). Pain score at 2 h after surgery was also significantly reduced in the TAP group compared with the CON group (P<0.05), whereas the time to first rescue analgesia was delayed in patients who received TAP block (P<0.05). Postoperative nausea and vomiting occurred at comparable rates in each group (P>0.05). In conclusion, TAP block combined with general anesthesia reduced propofol and remifentanil consumption, shortened time to tracheal extubation and promoted hemodynamic stability in laparoscopic colectomy.

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

BACKGROUND

Prolonged postoperative ileus (PPOI) is common after colorectal surgery but has not been widely studied in the context of enhanced recovery pathways (ERPs) that include interventions aimed to accelerate gastrointestinal recovery. The aim of this study is to estimate the incidence and predictors of PPOI in the context of an ERP for colorectal surgery.

METHODS

We analyzed data from an institutional colorectal surgery ERP registry. Incidence of PPOI was estimated according to a definition adapted from Vather (intolerance of solid food and absence of flatus or bowel movement for ≥ 4 days) and compared to other definitions in the literature. Potential risk factors for PPOI were identified from previous studies, and their predictive ability was evaluated using Bayesian model averaging (BMA). Results are presented as posterior effect probability (PEP). Evidence of association was categorized as: no evidence (PEP < 50%), weak evidence (50-75%), positive evidence (75-95%), strong evidence (95-99%), and very strong evidence (> 99%).

RESULTS

There were 323 patients analyzed (mean age 63.5 years, 51% males, 74% laparoscopic, 33% rectal resection). The incidence of PPOI was 19% according to the primary definition, but varied between 11 and 59% when using other definitions. On BMA analysis, intraoperative blood loss (PEP 99%; very strong evidence), administration of any intravenous opioids in the first 48 h (PEP 94%; strong evidence), postoperative epidural analgesia (PEP 56%; weak evidence), and non-compliance with intra-operative fluid management protocols (3 ml/kg/h for laparoscopic and 5 ml/kg/h for open; PEP 55%, weak evidence) were predictors of PPOI.

CONCLUSIONS

The incidence of PPOI after colorectal surgery is high even within an established ERP and varied considerably by diagnostic criteria, highlighting the need for a consensus definition. The use of intravenous opioids is a modifiable strong predictor of PPOI within an ERP, while the role of epidural analgesia and intraoperative fluid management should be further evaluated.

Preoperative Preparations for Enhanced Recovery After Surgery Programs: A Role for Prehabilitation

Preoperative risk assessment is valuable only if subsequent targeted optimization of patient care is allowed. Early assessment of high-risk surgical patients is essential to facilitate appropriate optimization. Preoperative assessment and optimization should not be exclusively focused on patients' comorbidities, but also include nutritional assessment, functional capacity, and promote healthy life style habits that affect surgical outcomes (eg, smoking cessation); it requires a multidisciplinary approach.

Survival After Emergency General Surgery: What can We Learn from Enhanced Recovery Programmes?

Enhanced recovery after surgery (ERAS) has been adopted by many centres and across whole healthcare systems. The results have shown significant reductions in length of stay and postoperative complications. However, there has been very little change in these factors and mortality in emergency surgery. Can we learn from principles of ERAS for emergency abdominal surgery?

Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program

INTRODUCTION

Guidelines recommend incorporation of more than 20 perioperative interventions within an enhanced recovery program (ERP). However, the impact of overall adherence to the pathway and the relative contribution of each intervention are unclear. The aim of this study was to estimate the extent to which adherence to ERP elements is associated with outcomes and identify key ERP elements predicting successful recovery following bowel resection.

METHODS

Prospectively collected data entered in a registry specifically designed for ERPs were reviewed. Patients undergoing elective bowel resection between 2012 and 2014 were treated within an ERP comprising 23 care elements. Primary outcome was successful recovery defined as the absence of complications, discharge by postoperative day 4 and no readmission. Secondary outcomes were length of hospital stay (LOS), 30-day morbidity, and severity (Comprehensive complication index, CCI, 0-100). Regression analyses were adjusted for potential confounders.

RESULTS

A total of 347 patients were included in the study. Median primary LOS was 4 days (IQR 3-7). Patients were adherent to median 18 (IQR 16-20) elements. A total of 156 (45 %) patients had successful recovery. Morbidity occurred in 175 (50 %) patients with median CCI 8.6 (IQR 0-22.6). There was a positive association between adherence and successful recovery (OR 1.39 for every additional element, p < 0.001), LOS (11 % reduction for every additional element, p < 0.001), 30-day postoperative morbidity (OR 0.78, p < 0.001), and the CCI (17 % reduction, p < 0.001). Laparoscopy (OR 4.32, p < 0.001), early mobilization out of bed (OR 2.25, p = 0.021), and early termination of IV fluid infusion (OR 2.00, p = 0.013) significantly predicted successful recovery. These factors were also associated with reduced morbidity and complication severity.

CONCLUSIONS

Increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity. In an established ERP where overall adherence was high, laparoscopic approach, perioperative fluid management, and patient mobilization remain key elements associated with improved outcomes.

'Blood doping' from Armstrong to prehabilitation: manipulation of blood to improve performance in athletes and physiological reserve in patients

Haemoglobin is the blood’s oxygen carrying pigment and is encapsulated in red blood corpuscles. The concentration of haemoglobin in blood is dependent on both its total mass in the circulation (tHb-mass) and the total plasma volume in which it is suspended. Aerobic capacity is defined as the maximum amount of oxygen that can be consumed by the body per unit time and is one measure of physical fitness. Observations in athletes who have undergone blood doping or manipulation have revealed a closer relationship between physical fitness (aerobic capacity) and total haemoglobin mass (tHb-mass) than with haemoglobin concentration ([Hb]). Anaemia is defined by the World Health Organisation (WHO) as a haemoglobin concentration of <130 g/L for men and <120 g/L for women. Perioperative anaemia is a common problem and is associated with increased mortality and morbidity following surgery. Aerobic capacity is also associated with outcome following major surgery, with less fit patients having a higher incidence of mortality and morbidity after surgery. Taken together, these observations suggest that targeted preoperative elevation of tHb-mass may raise aerobic capacity both directly and indirectly (by augmenting preoperative exercise initiatives- ‘prehabilitation’) and thus improve postoperative outcome. This notion in turn raises a number of questions. Which measure ([Hb] or tHb-mass) has the most value for the description of oxygen carrying capacity? Which measure has the most utility for targeting therapies to manipulate haemoglobin levels? Do the newer agents being used for blood manipulation (to increase tHb-mass) in elite sport have utility in the clinical environment? This review explores the literature relating to blood manipulation in elite sport as well as the relationship between perioperative anaemia, physical fitness and outcome following surgery, and suggests some avenues for exploring this area further.