Effect of intraoperative fluid volume on postoperative ileus after robot-assisted radical cystectomy

Identifying risk factors for postoperative ileus following open abdominal aortic aneurysm repair

BACKGROUND

Postoperative ileus (POI) is a common complication following major abdominal surgery. The majority of the data available regarding POI after abdominal surgery is from the gastrointestinal and urological literature. These data have been extrapolated to vascular surgery, especially with regard to enhanced recovery programs for open abdominal aortic aneurysm (AAA) surgery. However, vascular patients are a unique patient population and extrapolation of gastrointestinal and urological data may not necessarily be appropriate. Therefore, the purpose of this study was to delineate the prevalence and risk factors of POI in patients undergoing open AAA surgery.

METHODS

This was a retrospective, single-institution study of patients who underwent open AAA surgery from January 2016 to July 2023. Patients were excluded if they had undergone nonelective repairs or had expired within 72 hours of their index operation. The primary outcome was rates of POI, which was defined as the presence of two or more of the following after the third postoperative day: nausea and/or vomiting, inability to tolerate oral food intake, absence of flatus, abdominal distension, or radiological evidence of ileus.

RESULTS

A total of 123 patients met study criteria with an overall POI rate of 8.9% (n = 11). Patients who developed a POI had a significantly lower body mass index (24.3 kg/m2 vs 27.1 kg/m2; P = .003), were more likely to undergo a transperitoneal approach (81.8% vs 42.0%; P = .022), midline laparotomy (81.8% vs 37.5%; P = .008), longer total clamp times (151.6 minutes vs 97.7 minutes; P = .018), greater amounts of intraoperative crystalloid infusion (3495 mL vs 2628 mL; P = .029), and were more likely to return to the operating room (27.3% vs 3.6%; P = .016). Proximal clamp site was not associated with POI (P=.463). Patients with POI also had higher rates of postoperative vasopressor use (100% vs 61.1%; P = .014) and greater amounts of oral morphine equivalents in the first 3 postoperative days (488.0 ± 216.0 mg vs 203.8 ± 29.6 mg; P = .016). Patients who developed POI had longer lengths of stay (12.5 days vs 7.6 days; P < .001), a longer duration of nasogastric tube decompression (5.9 days vs 2.2 days; P < .001), and a longer period of time before diet tolerance (9.1 days vs 3.7 days; P < .001). Of those who developed a POI (n = 11), four (36.4%) required total parental nutrition during the admission.

CONCLUSIONS

POI is a morbid complication among patients undergoing elective open AAA surgery that prolongs hospital stay. Patients at risk for developing a POI are those with a lower body mass index, as well as those who had an operative repair via a transperitoneal approach, midline laparotomy, longer clamp times, larger amounts of intraoperative crystalloid infusion, a return to the operating room, postoperative vasopressor use, and higher amounts of oral morphine equivalents. These data highlight important perioperative opportunities to decrease the prevalence of POI.

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.

Validity of the I‑FEED classification in assessing postoperative gastrointestinal impairment in patients undergoing elective lumbar spinal surgery with general anesthesia: a prospective observational study

BACKGROUND

The I-FEED classification, scored 0-8, was reported to accurately describe the clinical manifestations of gastrointestinal impairment after colorectal surgery. Therefore, it is interesting to determine whether the I-FEED scoring system is also applicable to patients undergoing lumbar spine surgery.

METHODS

Adult patients undergoing elective lumbar spine surgery were enrolled, and the I-FEED score was measured for 4 days after surgery. The I-FEED scoring system incorporates five elements: intake (score: 0, 1, 3), feeling nauseated (score: 0, 1, 3), emesis (score: 0, 1, 3), results of physical exam (score: 0, 1, 3), and duration of symptoms (score: 0, 1, 2). Daily I-FEED scores were summed, and the highest overall score is used to categorize patients into one of three categories: normal (0-2 points), postoperative gastrointestinal intolerance (POGI; 3-5 points), and postoperative gastrointestinal dysfunction (POGD; 6 + points). The construct validity hypothesis testing determines whether the I-FEED category is consistent with objective clinical findings relevant to gastrointestinal impairment, namely, the longer length of hospital stay (LOS), higher inhospital medical cost, more postoperative gastrointestinal medical treatment, and more postoperative non-gastrointestinal complications.

RESULTS

A total of 156 patients were enrolled, and 25.0% of patients were categorized as normal, 49.4% POGI, and 25.6% POGD. Patients with higher I-FEED scores agreed with the four validity hypotheses. Patients with POGD had a significantly longer length of hospital stay (1 day longer median stay; p = 0.049) and more inhospital medical costs (approximately 500 Taiwanese dollars; p = 0.037), and more patients with POGD required rectal laxatives (10.3% vs. 32.5% vs. 32.5%; p = 0.026). In addition, more patients with POGD had non-gastrointestinal complications (5.1% vs. 11.7% vs. 30.0%; p = 0.034).

CONCLUSION

This study contributes preliminary validity evidence for the I-FEED score as a measure for postoperative gastrointestinal impairment after elective lumbar spine surgery.

Preoperative smoking and robot-assisted radical cystectomy outcomes & complications in multicenter KORARC database

To investigate the influence of preoperative smoking history on the survival outcomes and complications in a cohort from a large multicenter database. Many patients who undergo radical cystectomy (RC) have a history of smoking; however, the direct association between preoperative smoking history and survival outcomes and complications in patients with muscle-invasive bladder cancer (MIBC) who undergo robot-assisted radical cystectomy (RARC) remains unexplored. We conducted a retrospective analysis using data from 749 patients in the Korean Robot-Assisted Radical Cystectomy Study Group (KORARC) database, with an average follow-up duration of 30.8 months. The cohort was divided into two groups: smokers (n = 351) and non-smokers (n = 398). Propensity score matching was employed to address differences in sample size and baseline demographics between the two groups (n = 274, each). Comparative analyses included assessments of oncological outcomes and complications. After matching, smoking did not significantly affect the overall complication rate (p = 0.121). Preoperative smoking did not significantly increase the occurrence of complications based on complication type (p = 0.322), nor did it increase the readmission rate (p = 0.076). There were no perioperative death in either group. Furthermore, preoperative smoking history showed no significant impact on overall survival (OS) [hazard ratio (HR) = 0.87, interquartile range (IQR): 0.54-1.42; p = 0.589] and recurrence-free survival (RFS) (HR = 1.12, IQR: 0.83-1.53; p = 0.458) following RARC for MIBC. The extent of preoperative smoking (≤ 10, 10-30, and ≥ 30 pack-years) had no significant influence on OS and RFS in any of the categories (all p > 0.05). Preoperative smoking history did not significantly affect OS, RFS, or complications in patients with MIBC undergoing RARC.

Comparison of perioperative outcomes and complications between intracorporeal, extracorporeal, and hybrid ileal conduit urinary diversion during robot-assisted radical cystectomy: a comparative propensity score-matched analysis from nationwide multi-institutional study in Japan

BACKGROUND

To investigate the impact of different urinary diversion (UD) techniques on the peri- and postoperative complications of robot-assisted radical cystectomy (RARC) with ileal conduit.

METHODS

We retrospectively analyzed 373 patients undergoing RARC with ileal conduit at 11 institutions in Japan between April 2018 and December 2021. Propensity score weighting was performed to adjust for confounding factors such as age, sex, body mass index, performance status, American Society of Anesthesiologists score, previous abdominal surgery, neoadjuvant chemotherapy, and preoperative high T stage (≥ cT3) and high N stage (≥ cN1). Perioperative complications were then compared among three groups: extracorporeal, intracorporeal, and hybrid urinary diversion (ECUD, ICUD, and HUD, respectively).

RESULTS

A total of 150, 68, and 155 patients received ECUD, HUD, and ICUD, respectively. Bowel reconstruction time and UD time were significantly shorter in the ECUD group (p < 0.001), and console time was significantly longer and blood loss was significantly higher in the ICUD group (p < 0.001). For postoperative complications (Clavien-Dindo Classification grade ≥ 3), surgical site infection (p = 0.004), pelvic abscess (p = 0.013), anastomotic urine leak (p = 0.007), and pelvic organ prolapse (p = 0.011) significantly occurred in the ECUD group. For all grades, ileus was more common in the HUD group, whereas anastomotic stricture was more common in the ECUD group compared with the other groups (p < 0.05).

CONCLUSIONS

Severe complications did not increase after HUD and ICUD compared with ECUD; however, console time tended to be longer and blood loss was slightly higher during RARC.

Goal-directed fluid therapy using stroke volume variation on length of stay and postoperative gastrointestinal function after major abdominal surgery-a randomized controlled trial

BACKGROUND AND OBJECTIVE

The effectiveness of goal-directed fluid therapy (GDFT) in promoting postoperative recovery remains unclear, the aim of this study was to evaluate the effect of GDFT on length of hospital stay and postoperative recovery of GI function in patients undergoing major abdominal oncologic surgery.

METHODS

In this randomized, double- blinded, controlled trial, adult patients scheduled for elective major abdominal surgery with general anesthesia, were randomly divided into the GDFT protocol (group G) or conventional fluid therapy group (group C). Patients in group C underwent conventional fluid therapy based on mean arterial pressure (MAP) and central venous pressure (CVP) whereas those in group G received GDFT protocol associated with the SVV less than 12% and the cardiac index (CI) was controlled at a minimum of 2.5 L/min/m2. The primary outcomes were the length of hospital stay and postoperative GI function.

RESULTS

One hundred patients completed the study protocol. The length of hospital stay was significantly shorter in group G compared with group C [9.0 ± 5.8 days versus 12.0 ± 4.6 days, P = 0.001]. Postoperative gastrointestinal dysfunction (POGD) occurred in two of 50 patients (4%) in group G and 16 of 50 patients (32%) in the control group (P < 0.001). GDFT significantly also shorten time to first flatus by 11 h (P = 0.009) and time to first tolerate oral diet by 2 days (P < 0.001).

CONCLUSIONS

Guided by SVV and CI, the application of GDFT has the potential to expedite postoperative recovery of GI function and reduce hospitalization duration after major abdominal surgery.

TRIAL REGISTRATION

This study was registered on www.

CLINICALTRIALS

gov on 07/05/2019 with registration number: NCT03940144.

Identification of risk factors and clinical model construction of abdominal distension after radical cystectomy

Background

The occurrence of abdominal distention after radical cystectomy (RC) is common. We sought to determine risk factors of abdominal distention after RC, and to establish a simple and reliable nomogram for clinical risk assessment.

Methods

Clinical information on 139 patients who underwent RC from January 2020 to August 2021 was collected. The chi-square test, hypergeometric test, and univariate/multivariate logistic regression were utilized to explore the relationship between variables and abdominal distention after RC. A nomogram was then used to predict the probability of abdominal distension for the patients who underwent RC. Calibration and receiver operating characteristic (ROC) curves were used to evaluate the accuracy of the model.

Results

We found that 35 patients (25%) occurred in abdominal distention after RC. Among the patients, 7 of them developed intestinal obstruction. Postoperative water fasting time and abdominal surgery history were independent risk factors for abdominal distension after surgery. Finally, we constructed a risk model to predict the probability of abdominal distension after surgery. This model showed good fitting and calibration and excellent diagnostic performance with an area under the curve (AUC) of 0.804.

Conclusions

Postoperative water fasting time and abdominal surgery history were independent risk factors for abdominal distension after surgery. There was no significant difference in the incidence of postoperative abdominal distention between robot-assisted cystectomy and laparoscopic cystectomy.

Predicting factor analysis of postoperative complications after robot-assisted radical cystectomy: Multicenter KORARC database study

OBJECTIVES

To evaluate postoperative complications following robot-assisted radical cystectomy in patients diagnosed with bladder cancer and reveal if there are predictors for postoperative complications.

METHODS

Prospectively collected medical records of 730 robot-assisted radical cystectomy patients between 2007/04 and 2019/05 in 13 tertiary referral centers were reviewed. Perioperative outcomes were compared between two groups by postoperative complications (complication vs non-complication). We assessed recurrence-free survival, cancer-specific survival, and overall survival between groups. Regression analyses were implemented to identify factors associated with postoperative complications.

RESULTS

Any total and high-grade complication (Clavien-Dindo grade ≥3) rates were 57.8% and 21.1%, respectively. Patients in complication group had significantly higher proportion of diabetes mellitus (P = 0.048), chronic kidney disease (P = 0.011), dyslipidemia (P < 0.001), longer operation time (P = 0.001), more estimated blood loss (P = 0.001), and larger intraoperative fluid volume (P < 0.001). There was a significant difference in cancer-specific survival (log-rank P = 0.038, median cancer-specific survival: both groups not reached). Dyslipidemia (odds ratio 2.59, P = 0.002) and intraoperative fluid volume (odds ratio 1.0002, P = 0.040) were significantly associated with high-grade postoperative complications. Diabetes mellitus (odds ratio 1.97, P = 0.028), chronic kidney disease (odds ratio 1.89, P = 0.046), dyslipidemia (odds ratio 5.94, P = 0.007), and intraoperative fluid volume (odds ratio 1.0002, P = 0.009) were significantly associated with any postoperative complications.

CONCLUSIONS

Patients with diabetes mellitus, chronic kidney disease, dyslipidemia, or a relatively large intraoperatively infused fluid volume are more likely to develop postoperative complications. Patients with postoperative complications might have a possibility of lower cancer-specific survival rate.