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Quiroga-Centeno AC, Jerez-Torra KA, Martin-Mojica PA, Castañeda-Alfonso SA, Castillo-Sánchez ME, Calvo-Corredor OF, Gómez-Ochoa SA. Risk Factors for Prolonged Postoperative Ileus in Colorectal Surgery: A Systematic Review and Meta-analysis. World J Surg 2021; 44:1612-1626. [PMID: 31912254 DOI: 10.1007/s00268-019-05366-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Sergio Alejandro Gómez-Ochoa
- Member Grupo de Investigación en Cirugía y Especialidades Quirúrgicas (GRICES-UIS), School of Medicine, Health Sciences Faculty, Universidad Industrial de Santander, Street 32 · 29-31, Bucaramanga, Colombia.
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Abstract
STUDY DESIGN Retrospective database study. OBJECTIVE We sought to identify trends in demographics, comorbidities, and postoperative complications among patients undergoing ACDF and PLF. SUMMARY OF BACKGROUND DATA As demand for anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF) surgery continues to increase, it is important to understand changes in the healthcare system and patient populations undergoing these procedures. METHODS We identified 220,520 ACDF and 151,547 PLF surgeries (2006-2016; Premier Healthcare database). Annual proportions or medians were calculated for patient and hospital characteristics, and (Elixhauser) comorbidities. Postoperative complications, including blood transfusions, cardiovascular, pulmonary, renal, or wound complications, hemorrhage, stroke, sepsis, thromboembolism, delirium, inpatient falls, and mortality, were reported per 1000 inpatient days. Trends were assessed by Cochran-Armitage tests and linear regression for binary and continuous variables, respectively. RESULTS The median age of patients undergoing ACDF and PLF increased significantly from 2006 to 2016 (50 to 57 yr and 58 to 61 yr, respectively; P < 0.001) coinciding with an increasing comorbidity burden (30.2% to 47.9% and 44.9% to 55.7%, respectively representing the share of patients with ≥2 Elixhauser comorbidities; P < 0.001). Overall rate of any complication experienced a significant decline after both ACDF (24.5 to 20.8 per 1000 inpatient days; P = 0.002) and PLF (30.5 to 23.1 per 1000 inpatient days; P < 0.001). CONCLUSIONS The comorbidity burden of patients undergoing ACDF and PLF increased substantially from 2006 to 2016, however without a corresponding increase in overall complication rate. Understanding these changes can help guide future practice, advise in the allocation of resources, and inform future areas of research. LEVEL OF EVIDENCE 3.
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Mishra K, Fernstrum A, Mahran A, Sidagam V, Adamic B, Shekar A, Calaway A, Nguyen C, Ponsky L, Bukavina L. Epidural Anesthesia is Associated With Increased Complications in Cystectomy Patients: A NSQIP Analysis. Urology 2020; 138:77-83. [PMID: 31954167 DOI: 10.1016/j.urology.2020.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 11/28/2019] [Accepted: 01/06/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To identify differences in short-term outcomes and readmission rates in cystectomy patients managed with general anesthesia compared to those undergoing general anesthesia and adjuvant epidural anesthesia. METHODS Utilizing the National Surgical Quality Inpatient Program database, patients who underwent a cystectomy with ileal conduit between 2014 and 2017 were included. Patients were further subdivided based on additional anesthesia modality; general anesthesia vs general anesthesia plus epidural anesthesia. Propensity score-matching was used to adjust for baseline differences between cohorts using 1:1 caliper width of 0.15 for the propensity score through the nearest neighbor. Stepwise multivariable logistic regression was used to identify preoperative and intraoperative predictors associated with 30-day procedure related readmission, complications, and length of stay. RESULTS About 2956 patients met our inclusion and exclusion criteria and eligible for propensity score matching. Compared to general anesthesia, adjuvant epidural anesthesia showed an increased odds of procedure related complications (adjusted Odds Ratio (aOR): 1.264, 95% CI: 1.019-1.567, P = .033). There was an increased trend for development of pulmonary emboli (13 [1.8%] vs 4 [0.5%], P = .051) in the adjuvant epidural cohort. Combined general with epidural anesthesia demonstrated no difference in length of stay, readmission, or reoperation rate in comparison to general anesthesia alone. CONCLUSION Cystectomy patients who underwent general anesthesia plus epidural anesthesia demonstrated a higher percentage of any procedural related complication without change in postoperative stay, reoperation rate, or readmission rate compared to patients undergoing general anesthesia alone.
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Affiliation(s)
- Kirtishri Mishra
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Austin Fernstrum
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH.
| | - Amr Mahran
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH
| | - Vasu Sidagam
- University Hospitals Cleveland Medical Center, Department of Perioperative Medicine, Cleveland, OH
| | | | - Anjali Shekar
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Adam Calaway
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Carvell Nguyen
- Case Western Reserve University School of Medicine, Cleveland, OH; Metro Health Medical Center, Cleveland, OH
| | - Lee Ponsky
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Laura Bukavina
- Case Western Reserve University School of Medicine, Cleveland, OH; University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, OH; Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, OH
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Is there a benefit to additional neuroaxial anesthesia in open nephrectomy? A prospective NSQIP propensity score analysis. Int Urol Nephrol 2019; 51:1481-1489. [PMID: 31222441 DOI: 10.1007/s11255-019-02208-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 06/13/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Neuroaxial (i.e., spinal, regional, epidural) anesthesia has been shown to be associated with reduced readmission rate, decreased hospital stay, and decreased overall complication rate in orthopedic and gynecologic surgery. Our aim was to identify differences in intra- and postoperative complications, length of stay and readmission rates in open nephrectomy patients managed with neuroaxial anesthesia. MATERIALS AND METHODS Utilizing National Surgical Quality Inpatient Program (NSQIP) database, we identified patients who have undergone an open nephrectomy between 2014 and 2017. Patients were further subdivided based on anesthesia modality. We used the propensity score-matching (PSM) method to adjust for baseline differences among patients who received general anesthesia alone and those with additional neuroaxial anesthesia. Using step-wise multivariable logistic regression, we identified preoperative and intraoperative predictors associated with 30-day procedure-related readmission, complications, and postoperative length of stay. RESULTS Out of 3,633 patients identified, 2346 patients met our inclusion and exclusion criteria. There was no difference in baseline characteristics after propensity score matching between general and additional neuroaxial anesthesia. Postoperative outcomes including: procedure-related readmission, rate of reoperation, operative time, all complications were similar between the groups. Adjuvant neuroaxial anesthesia group did experience a prolonged postoperative hospital stay that was statistically significant as compared to patients with general anesthesia alone [5.3 (3.5) days vs 4.8 (2.9) days, p = 0.007]. Compared to GA alone after multivariable logistic regression, neuroaxial anesthesia was not statistically significant for readmission (p = 0.909), any complication (p = 0.505), but did showed increased odds ratio of prolonged postoperative stay [aOR 1.107, 95% CI 1.042-1.176, p = 0.001] after adjusting for multiple factors. CONCLUSION Using 2014-2017 NSQIP database, we were able to demonstrate no additional reduction in complication or readmission rate in patients with neuroaxial anesthesia as compared to general anesthesia alone. Furthermore, patients who did receive neuroaxial anesthesia experienced a longer postoperative course.
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Smith LM, Cozowicz C, Uda Y, Memtsoudis SG, Barrington MJ. Neuraxial and Combined Neuraxial/General Anesthesia Compared to General Anesthesia for Major Truncal and Lower Limb Surgery. Anesth Analg 2017; 125:1931-1945. [DOI: 10.1213/ane.0000000000002069] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Abstract
BACKGROUND Despite numerous trials assessing optimal antibiotic prophylaxis strategies for colorectal surgery, few studies have assessed real-world practice on a national scale with respect to risk of surgical site infections. OBJECTIVE Using a large national claims database we aimed to describe current use of prophylactic antibiotics (type and duration) and associations with surgical site infection after open colectomies. DESIGN This was a retrospective study using the Premier Perspective database. SETTINGS Included were patient hospitalizations nationwide from January 2006 to December 2013. PATIENTS A total of 90,725 patients who underwent an open colectomy in 445 different hospitals were included in the study. MAIN OUTCOME MEASURES Multilevel, multivariable logistic regressions measured associations between surgical site infection and type of antibiotic used and duration (day of surgery only, day of surgery and the day after, and >1 day after surgery). RESULTS Overall surgical site infection prevalence was 5.2% (n = 4750). Most patients (41.8%) received cefoxitin for prophylaxis; other choices were ertapenem (18.2%), cefotetan (10.3%), metronidazole with cefazolin (9.9%), and ampicillin with sulbactam (7.6%), whereas 12.2% received other antibiotics. Distribution of prophylaxis duration was 51.6%, 28.5%, and 19.9% for day of surgery only, day of surgery and the day after, and >1 day after surgery, respectively. Compared with cefoxitin, lower odds for surgical site infection were observed for ampicillin with sulbactam (OR = 0.71 (95% CI, 0.63-0.82)), ertapenem (OR = 0.65 (95% CI, 0.58-0.71)), metronidazole with cefazolin (OR = 0.56 (95% CI, 0.49-0.64)), and "other" (OR = 0.81 (95% CI, 0.73-0.90)); duration was not significantly associated with altered odds for surgical site infection. Sensitivity analyses supported the main findings. LIMITATIONS The study was limited by its lack of detailed clinical information in the billing data set used. CONCLUSIONS In this national study assessing real-world use of prophylactic antibiotics in open colectomies, the type of antibiotic used appeared to be associated with up to 44% decreased odds for surgical site infections. Although there are numerous trials on optimal prophylactic strategies, studies that particularly focus on factors that influence the choice of prophylactic antibiotic might provide insights into ways of reducing the burden of surgical site infections in colorectal surgeries.
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Neuman MD. Understanding outcomes after neuraxial anaesthesia: time to turn the page. Br J Anaesth 2015; 116:15-7. [PMID: 26487154 DOI: 10.1093/bja/aev353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- M D Neuman
- Department of Anesthesiology and Critical Care Department of Internal Medicine, Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Drive, 308 Blockley Hall, Philadelphia, PA 19104, USA Leonard Davis Institute for Health Economics, The University of Pennsylvania, Philadelphia, PA, USA
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Cata JP, Lasala J, Bugada D. Best practice in the administration of analgesia in postoncological surgery. Pain Manag 2015; 5:273-84. [PMID: 26072922 DOI: 10.2217/pmt.15.21] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The rationale for using multimodal analgesia after any major surgery is achievement of adequate analgesia while avoiding the unwanted effects of large doses of any analgesic, in particular opioids. There are two reasons why we can hypothesize that multimodal analgesia might have a significant impact on cancer-related outcomes in the context of oncological orthopedic surgery. First, because multimodal analgesia is a key component of enhanced-recovery pathways and can accelerate return to intended oncological therapy. And second, because some of the analgesic used in multimodal analgesia (i.e., COX inhibitors, local analgesics and dexamethasone) can induce apoptosis in cancer cells and/or diminish the inflammatory response during surgery which itself can facilitate tumor growth.
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Affiliation(s)
- Juan P Cata
- Department of Anesthesiology & Perioperative Medicine, The University of Texas-MD Anderson Cancer Center, Houston, TX 77030, USA.,Anesthesia & Surgical Oncology Research Group
| | - Javier Lasala
- Department of Anesthesiology & Perioperative Medicine, The University of Texas-MD Anderson Cancer Center, Houston, TX 77030, USA.,Anesthesia & Surgical Oncology Research Group
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Impact of Regional Anesthesia on Perioperative Outcomes. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0101-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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