Prediction of Prolonged Postoperative Ileus After Radical Gastrectomy for Gastric Cancer: A Scoring System Obtained From a Prospective Study

Surgical outcomes and prognosis of intracorporeal versus extracorporeal esophagojejunostomy after laparoscopic total gastrectomy for gastric cancer: a propensity score-matching study

This study compared the surgical outcomes and long-term prognosis of intracorporeal and extracorporeal esophagojejunostomy after laparoscopic total gastrectomy (LTG) for gastric cancer patients. In total 228 clinical stage I gastric cancer patients undergoing LTG were enrolled from January 2012 and December 2022. Each case in the totally laparoscopic total gastrectomy (TLTG) group was 1:1 propensity score-matched to control cases in the laparoscopy-assisted total gastrectomy (LATG) group. In total, 95 and 93 LATG and TLTG patients were included after propensity score matching (PSM). Clinicopathological features, surgical outcomes, and survival variables were compared, and risk factors for postoperative complications were analyzed. Patient characteristics were well balanced between the LATG and TLTG groups after PSM. The TLTG group showed less blood loss, decreased frequency of analgesic use, and shorter duration of analgesic use. The TLTG group had significantly lower rates of intestinal obstruction and surgical site infection. Larger tumor size and advanced pTNM stage were independent risk factors for postoperative complications. There was no significant difference in overall survival (OS). Compared with LATG, TLTG was associated with better surgical outcomes and fewer postoperative surgical complications in gastric cancer patients although there was no significant difference in OS.

Prognostic factors associated with gastrointestinal dysfunction after gastrointestinal tumor surgery: A meta-analysis

BACKGROUND

Explore the risk factors of gastrointestinal dysfunction after gastrointestinal tumor surgery and to provide evidence for the prevention and intervention of gastrointestinal dysfunction in patients with gastrointestinal tumor surgery.

AIM

To investigate the potential risk factors for gastrointestinal dysfunction following gastrointestinal tumor surgery and to present information supporting the prevention and management of gastrointestinal dysfunction in surgery patients.

METHODS

Systematically searched the relevant literature from PubMed, Web of Science, Cochrane Library, Embase, CNKI, China Biomedical Database, Wanfang Database, and Weipu Chinese Journal Database self-established until October 1, 2022. Review Manager 5.3 software was used for meta-analysis after two researchers independently screened literature, extracted data, and evaluated the risk of bias in the included studies.

RESULTS

A total of 23 pieces of literature were included, the quality of which was medium or above, and the total sample size was 43878. The results of meta-analysis showed that the patients were male (OR = 1.58, 95%CI: 1.25-2.01, P = 0.002) and ≥ 60 years old (OR = 2.60, 95%CI: 1.76-2.87, P < 0.001), physical index ≥ 25.3 kg/m2 (OR = 1.6, 95%CI: 1.00-1. 12, P = 0.040), smoking history (OR = 1.89, 95%CI: 1.31-2.73, P < 0.001), chronic obstructive pulmonary disease (OR = 1.49, 95%CI: 1.22-1.83, P < 0.001), enterostomy (OR = 1.47, 95%CI: 1.26-1.70, P < 0.001), history of abdominal surgery (OR = 2.90, 95%CI: 1.67-5.03, P < 0.001), surgical site (OR = 1.2, 95%CI: 1.40-2.62, P < 0.001), operation method (OR = 1.68, 95%CI: 1.08-2.62, P = 0.020), operation duration (OR = 2.65, 95%CI: 1.92-3.67, P < 0.001), abdominal adhesion grade (OR = 2.52, 95%CI: 1.90-3.56, P < 0.001), postoperative opioid history (OR = 5.35, 95%CI: 3.29-8.71, P < 0.001), tumor TNM staging (OR = 2.58, 95%CI: 1.84-3.62, P < 0.001), postoperative blood transfusion (OR = 2.92, 95%CI: 0.88-9.73, P = 0.010) is a risk factor for postoperative gastrointestinal dysfunction in patients with gastrointestinal tumors.

CONCLUSION

There are many factors affecting gastrointestinal dysfunction in gastrointestinal patients after surgery. Clinical staff should identify relevant risk factors early and implement targeted intervention measures on the basis of personalized assessment to improve the clinical prognosis of patients.

Revolutionizing Postoperative Ileus Monitoring: Exploring GRU-D's Real-Time Capabilities and Cross-Hospital Transferability

Background

Postoperative ileus (POI) after colorectal surgery leads to increased morbidity, costs, and hospital stays. Identifying POI risk for early intervention is important for improving surgical outcomes especially given the increasing trend towards early discharge after surgery. While existing studies have assessed POI risk with regression models, the role of deep learning's remains unexplored.

Methods

We assessed the performance and transferability (brutal force/instance/parameter transfer) of Gated Recurrent Unit with Decay (GRU-D), a longitudinal deep learning architecture, for real-time risk assessment of POI among 7,349 colorectal surgeries performed across three hospital sites operated by Mayo Clinic with two electronic health records (EHR) systems. The results were compared with atemporal models on a panel of benchmark metrics.

Results

GRU-D exhibits robust transferability across different EHR systems and hospital sites, showing enhanced performance by integrating new measurements, even amid the extreme sparsity of real-world longitudinal data. On average, for labs, vitals, and assisted living status, 72.2%, 26.9%, and 49.3% respectively lack measurements within 24 hours after surgery. Over the follow-up period with 4-hour intervals, 98.7%, 84%, and 95.8% of data points are missing, respectively. A maximum of 5% decrease in AUROC was observed in brutal-force transfer between different EHR systems with non-overlapping surgery date frames. Multi-source instance transfer witnessed the best performance, with a maximum of 2.6% improvement in AUROC over local learning. The significant benefit, however, lies in the reduction of variance (a maximum of 86% decrease). The GRU-D model's performance mainly depends on the prediction task's difficulty, especially the case prevalence rate. Whereas the impact of training data and transfer strategy is less crucial, underscoring the challenge of effectively leveraging transfer learning for rare outcomes. While atemporal Logit models show notably superior performance at certain pre-surgical points, their performance fluctuate significantly and generally underperform GRU-D in post-surgical hours.

Conclusion

GRU-D demonstrated robust transferability across EHR systems and hospital sites with highly sparse real-world EHR data. Further research on built-in explainability for meaningful intervention would be highly valuable for its integration into clinical practice.

Effect of Short-Term Preoperative Parenteral Nutrition Support for Gastric Cancer Patients with Sarcopenia: a Propensity Score Matching Analysis

INTRODUCTION

Sarcopenia is well recognized as an unfavorable prognostic marker for gastric cancer (GC) patients. Currently, few nutritional interventions-such as parenteral nutrition-exist for the treatment of patients with sarcopenia. This study aimed to estimate the effectiveness of short-term preoperative parenteral nutrition (PN) in GC patients with sarcopenia.

MATERIALS AND METHODS

We collected data on GC patients with sarcopenia who underwent radical gastrectomy at our hospital from 2010 to 2018. A 1:1 ratio propensity score matching (PSM) was applied to establish the PN and control groups. Data were analyzed using the chi-squared, Mann-Whitney U, and Fisher's exact tests.

RESULTS

In total, 428 patients met the inclusion criteria, and the propensity scores identified 166 matched pairs of patients with sarcopenia. The overall incidence of postoperative complications between both groups was not significantly different (P = 0.728). The PN group had a lower rate of intra-abdominal infection (P = 0.032) and higher hospitalization costs (P < 0.001) than the control group. Multivariate analysis demonstrated that age, Charlson score, and TNM stage were independent risk factors for postoperative complications. Additionally, subgroup analysis revealed that short-term preoperative PN support is associated with decreased postoperative surgical complications in patients with albumin levels < 35 g/L (P = 0.025).

CONCLUSION

Short-term preoperative PN support is not associated with reduction of overall complication rate in patients with GC and sarcopenia. However, those with sarcopenia and hypoalbuminemia benefited from preoperative PN support.

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.

Actual compliance rate of Enhanced Recovery After Surgery protocol in laparoscopic distal gastrectomy

Purpose

The Enhanced Recovery After Surgery (ERAS) protocol enhances recovery rate after laparoscopic distal gastrectomy (LDG). An ERAS protocol has been applied to most patients who underwent LDG at our center. In this study, we determined the actual compliance rate of the ERAS protocol and analyzed the risk factors for noncompliance.

Methods

Medical records of 1,013 patients who underwent LDG from March 2016 to December 2017 were reviewed retrospectively. The compliance group (A) included 327 patients who were discharged within four days postoperatively. The noncompliance group (B) comprised 686 patients who were not discharged within four days postoperatively.

Results

The compliance rate of the ERAS protocol was 32.3%. Potential compliance rate was 53.2%. Most common reasons for noncompliance were fever (n = 115) and ileus (n = 111). The 30-day emergency room visit rate was significantly lower in group A than that in group B (p = 0.006). Median age, American Society of Anesthesiologists (ASA) physical status classification, operation time, and pathologic stage were significantly higher in group B than those in group A (p < 0.001, p < 0.001, p = 0.005, and p < 0.001, respectively). Risk factors for noncompliance were ASA classification of ≥III (odds ratio [OR], 2.251; p = 0.007), age of ≥70 years (OR, 1.572; p = 0.004), operation time of ≥180 minutes (OR, 1.475; p = 0.003), and pathologic stage of ≥III (OR, 2.224; p < 0.001).

Conclusion

The current ERAS protocols should be applied to patients without risk factors.

Post-operative ileus: definitions, mechanisms and controversies

Post-operative ileus (POI) is a syndrome of impaired gastrointestinal transit which occurs following abdominal surgery. There are few effective targeted therapies for ileus, and research has been limited by inconsistent definitions and an incomplete understanding of the underlying pathophysiology. Despite considerable effort, there remains no widely-adopted definition of ileus, and recent work has identified variation in outcome reporting is a major source of heterogeneity in clinical trials. Outcomes should be clearly-defined, clinically-relevant, and reflective of the underlying biology, impacts on hospital resources and quality of life. Further collaborative efforts will be needed to develop consensus definitions and a core outcome set for postoperative gastrointestinal recovery. Investigation into the pathophysiology of POI has been hindered by use of low-resolution techniques and difficulties linking cellular mechanisms to dysmotility patterns and clinical symptoms. Recent evidence has suggested the common assumption of post-operative GI paralysis is incorrect, and that the distal colon becomes hyperactive following surgery. The post-operative inflammatory response is important in the pathophysiology of ileus, but the time course of this in humans remains unclear, with the majority of evidence coming from animal models. Future work should investigate dysmotility patterns underlying ileus, and identify biomarkers which may be used to diagnose, monitor and stratify patients with ileus.

Early enteral nutrition after head and neck surgery with free tissue transfer reconstruction

OBJECTIVE

Early enteral nutrition is essential for enhancing recovery after surgery. However, to date, no detailed study has been conducted on the feasibility of early enteral nutrition in patients undergoing head and neck surgery with free tissue transfer reconstruction (HNS-FTTR) and the risk factors for difficulty with early enteral nutrition.

METHODS

We retrospectively analyzed 102 patients who underwent HNS-FTTR at our institution; 61 underwent free jejunal reconstruction (FJ) and 41 did not. We investigated the achievement of early enteral nutrition within 24 and 48 h after surgery and the discontinuation of enteral nutrition after its initiation within 7 days after surgery.

RESULTS

Enteral nutrition could be started in 81/102 (79.4%) and 99/102 (97.1%) patients within 24 and 48 h, respectively. Cases of difficulty with early enteral nutrition accounted for 21/102 (20.6%) patients. The multivariate analysis revealed that FJ was a significant independent risk factor for difficulty with early enteral nutrition (odds ratio: 4.054, P = 0.042). The risk factors for difficulty with early enteral nutrition in patients who underwent FJ were also investigated, and the multivariate analysis showed that blood loss of ≥158 mL was a significant independent risk factor (odds ratio: 3.505, P = 0.044).

CONCLUSIONS

Early enteral nutrition seemed to be provided with no problems in patients without FJ. FJ was a significant risk factor for difficulty with early enteral nutrition. Increased intraoperative blood loss was a significant risk factor for difficulty with early enteral nutrition in patients undergoing FJ; therefore, patients' abdominal symptoms and gastric residual volume should be carefully monitored in such cases.

Men and Those With a History of Smoking Are Associated With the Development of Postoperative Ileus Following Elective Colorectal Cancer Resection at a Private Academic Hospital in Johannesburg, South Africa: A Retrospective Cohort Study

Introduction: A scarcity of local published data on colorectal cancer (CRC) postoperative complications, including postoperative ileus (POI), exists. POI is a temporary gastrointestinal (GI) state of absent or reduced gastric motility shown to increase patient morbidity, prolong length-of-stay (LOS), and intensify the healthcare resource burden. The pathogenesis of POI involves a neurogenic and inflammatory phase plus a pharmacological component. Aim and Objectives: This study aimed to determine centre-specific preoperative risk factors associated with the development of ileus post elective therapeutic CRC resection. The objectives were to determine whether patient demographics; functional status; comorbidities; GI history; pharmacotherapy (including neoadjuvant chemotherapy); and lastly neoadjuvant radiation and chemoradiation were associated with the development of POI. Method: Patients who underwent CRC resection between January 2016 and May 2019 were retrospectively identified from an existing database. Urgent-or non-therapeutic surgeries; surgeries with the complication anastomotic leak or GI obstruction; patients under 18 at the time of surgery or surgeries preceded by preoperative parenteral nutrition were excluded. A comparison was done of the incidence of exposure in the study cohort to investigated variables as potential risk factors for the complication POI. Results: A total of 155 patient cases were included, and 56 (36%) of them developed POI. Univariate comparison of patients who developed POI with demographic characteristics of patients who did not suggested that women were at lower risk to develop POI compared to men (p = 0,013; RR 0,56; 95% CI 0,36-0,89). Functional status suggested that all previous smokers were at a higher risk to develop POI compared to lifetime non-smokers (p = 0,0069; RR 1,78; 95% CI 1,17-2,70). Multivariable comparison of ≤ 5 qualifying parameters showed no significance. Conclusion: The high local incidence of POI in this patient population shows that intervention is required to reduce the POI rate and improve postoperative outcomes. This study suggests that for men and all patients with a history of smoking both, CRC resection preoperative recommendations with the intention to prevent POI should include instructions initiating the activation of preventive strategies like the Enhanced Recovery After Surgery (ERAS) programme. More studies are needed to adequately determine local perioperative risk factors for POI.

Preoperative albumin levels predict prolonged postoperative ileus in gastrointestinal surgery

BACKGROUND

Prolonged postoperative ileus (PPOI) is a prolonged state of “pathological” gastrointestinal (GI) tract dysmotility. There are relatively few studies examining the influence of preoperative nutritional status on the development of PPOI in patients who underwent GI surgery. The association between preoperative albumin and PPOI has not been fully studied. We hypothesized that preoperative albumin may be an independent indicator of PPOI.

AIM

To analyze the role of preoperative albumin in predicting PPOI and to establish a nomogram for clinical risk evaluation.

METHODS

Patients were drawn from a prospective hospital registry database of GI surgery. A total of 311 patients diagnosed with gastric or colorectal cancer between June 2016 and March 2017 were included. Potential predictors of PPOI were analyzed by univariate and multivariable logistic regression analyses, and a nomogram for quantifying the presence of PPOI was developed and internally validated.

RESULTS

The overall PPOI rate was 21.54%. Advanced tumor stage and postoperative opioid analgesic administration were associated with PPOI. Preoperative albumin was an independent predictor of PPOI, and an optimal cutoff value of 39.15 was statistically calculated. After adjusting multiple variables, per unit or per SD increase in albumin resulted in a significant decrease in the incidence of PPOI of 8% (OR = 0.92, 95%CI: 0.85-1.00, P = 0.046) or 27% (OR = 0.73, 95%CI: 0.54-0.99, P = 0.046), respectively. Patients with a high level of preoperative albumin (≥ 39.15) tended to experience PPOI compared to those with low levels (< 39.15) (OR = 0.43, 95%CI: 0.24-0.78, P = 0.006). A nomogram for predicting PPOI was developed [area under the curve (AUC) = 0.741] and internally validated by bootstrap resampling (AUC = 0.725, 95%CI: 0.663-0.799).

CONCLUSION

Preoperative albumin is an independent predictive factor of PPOI in patients who underwent GI surgery. The nomogram provided a model to screen for early indications in the clinical setting.

Development of a risk-stratification scoring system for predicting lymphovascular invasion in breast cancer

Background

Lymphovascular invasion (LVI) is a vital risk factor for prognosis across cancers. We aimed to develop a scoring system for stratifying LVI risk in patients with breast cancer.

Methods

A total of 301 consecutive patients (mean age, 49.8 ± 11.0 years; range, 29–86 years) with breast cancer confirmed by pathological reports were retrospectively evaluated at the authors’ institution between June 2015 and October 2018. All patients underwent contrast-enhanced Magnetic Resonance Imaging (MRI) examinations before surgery. MRI findings and histopathologic characteristics of tumors were collected for analysis. Breast LVI was confirmed by postoperative pathology. We used a stepwise logistic regression to select variables and two cut-points were determined to create a three-tier risk-stratification scoring system. The patients were classified as having low, moderate and high probability of LVI. The area under the receiver operating characteristic curve (AUC) was used to evaluate the discrimination ability of the scoring system.

Results

Tumor margins, lobulation sign, diffusion-weighted imaging appearance, MRI-reported axillary lymph node metastasis, time to signal intensity curve pattern, and HER-2 were selected as predictors for LVI in the point-based scoring system. Patients were considered at low risk if the score was < 3.5, moderate risk if the score was 3.5 to 6.0, and high risk if the score was ≥6.0. LVI risk was segmented from 0 to 100.0% and was positively associated with an increase in risk scores. The AUC of the scoring system was 0.824 (95% confidence interval [CI]: 0.776--0.872).

Conclusion

This study shows that a simple and reliable score-based risk-stratification system can be practically used in stratifying the risk of LVI in breast cancer.

A systematic review and meta-analysis of baseline risk factors for the development of postoperative ileus in patients undergoing gastrointestinal surgery

INTRODUCTION

Postoperative ileus occurs frequently following abdominal surgery. Identification of groups at high risk of developing ileus before surgery may allow targeted interventions. This review aimed to identify baseline risk factors for ileus.

METHODS

A systematic review was conducted with reference to PRISMA and MOOSE guidelines. It was registered on PROSPERO (CRD42017068697). Searches of MEDLINE, EMBASE and CENTRAL were undertaken. Studies reporting baseline risk factors for the development of postoperative ileus based on cohort or trial data and published in English were eligible for inclusion. Dual screening of abstracts and full texts was undertaken. Independent dual extraction was performed. Bias assessment was undertaken using the quality in prognostic studies tool. Meta-analysis using a random effects model was undertaken where two or more studies assessed the same variable.

FINDINGS

Searches identified 2,430 papers, of which 28 were included in qualitative analysis and 12 in quantitative analysis. Definitions and incidence of ileus varied between studies. No consistent significant effect was found for association between prior abdominal surgery, age, body mass index, medical comorbidities or smoking status. Male sex was associated with ileus on meta-analysis (odds ratio 1.12, 95% confidence interval 1.02-1.23), although this may reflect unmeasured factors. The literature shows inconsistent effects of baseline factors on the development of postoperative ileus. A large cohort study using consistent definitions of ileus and factors should be undertaken.

Nomogram to predict prolonged postoperative ileus after gastrectomy in gastric cancer

BACKGROUND

Prolonged postoperative ileus (PPOI) is one of the common complications in gastric cancer patients who underwent gastrectomy. Evidence on the predictors of PPOI after gastrectomy is limited and few prediction models of nomogram are used to estimate the risk of PPOI. We hypothesized that a predictive nomogram can be used for clinical risk estimation of PPOI in gastric cancer patients.

AIM

To investigate the risk factors for PPOI and establish a nomogram for clinical risk estimation.

METHODS

Between June 2016 and March 2017, the data of 162 patients with gastrectomy were obtained from a prospective and observational registry database. Clinical data of patients who fulfilled the criteria were obtained. Univariate and multivariable logistic regression models were performed to detect the relationship between variables and PPOI. A nomogram for PPOI was developed and verified by bootstrap resampling. The calibration curve was employed to detect the concentricity between the model probability curve and ideal curve. The clinical usefulness of our model was evaluated using the net benefit curve.

RESULTS

This study analyzed 14 potential variables of PPOI in 162 gastric cancer patients who underwent gastrectomy. The incidence of PPOI was 19.75% in patients with gastrectomy. Age older than 60 years, open surgery, advanced stage (III–IV), and postoperative use of opioid analgesic were independent risk factors for PPOI. We developed a simple and easy-to-use prediction nomogram of PPOI after gastrectomy. This nomogram had an excellent diagnostic performance [area under the curve (AUC) = 0.836, sensitivity = 84.4%, and specificity = 75.4%]. This nomogram was further validated by bootstrapping for 500 repetitions. The AUC of the bootstrap model was 0.832 (95%CI: 0.741–0.924). This model showed a good fitting and calibration and positive net benefits in decision curve analysis.

CONCLUSION

We have developed a prediction nomogram of PPOI for gastric cancer. This novel nomogram might serve as an essential early warning sign of PPOI in gastric cancer patients.

Prolonged postoperative ileus in gastric surgery: Is there any difference between laparoscopic and open surgery?

BACKGROUND

Prolonged postoperative ileus (PPOI) is a common complication after abdominal surgery, but data about risk factors of PPOI for patients with gastric cancer are rare. We sought to investigate the impact of laparoscopic versus open surgery for PPOI after gastric cancer surgery.

METHODS

A retrospective cohort study was conducted using a registry database consecutively collected from June 2016 to March 2017. PPOI was defined as no bowel function persisting for more than 4 days. Univariate analysis and multiple logistic regression models were performed to investigate risk factors, and stratified analysis was carried out to examine the primary association at different levels of a potential confounding factor.

RESULTS

A total of 162 patients composed of 63 patients undergoing laparotomy and 99 patients undergoing laparoscopy were enrolled and PPOI was observed in 32 (19.75%) patients. Risk factors significantly correlated with PPOI were as follows: open surgery, older age, late surgical pathologic staging, postoperative use of opioid analgesic, low level of postoperative albumin and serum potassium. Compared to open surgery, the laparoscopic surgery was a strong protective factor for PPOI after adjusting related variables (OR = 0.17, CI: 0.05-0.52, P = .002). There was an interaction between surgical methods and the postoperative WBC level (P for interaction = .007). In the two group stratified analysis of WBC, laparoscopic surgery had a significant lower risk of PPOI than open group for the patients with WBC counts above the middle level in crude or adjusted models. This result remained significantly in the three group stratified analysis for the patients with WBC counts in the middle and or high tertile groups.

CONCLUSIONS

PPOI is a common postoperative complication of patients after gastrectomy. Laparoscopic surgery is associated with decreased risk of PPOI in gastric surgery. Patients who underwent open surgery and presented with high level of WBC should be cautious with PPOI.

The risk factors for postoperative ileus following posterior thoraco-lumbar spinal fusion surgery

OBJECTIVE

Postoperative ileus (PI) is a common complication following posterior thoraco-lumbar spinal fusion surgery. It usually slows patient's recovery and increases postoperative morbidity. However, the risk factors associated with PI in patients undergoing posterior thoraco-lumbar spinal fusion surgery are still unclear. The purpose of this study is to investigate the potential risk factors for PI in those patients.

PATIENTS AND METHODS

A prospective study was conducted and 426 patients received posterior thoraco-lumbar spinal fusion surgery between March 2017 and February 2018 were included in this study. The associations between different clinical factors and PI were analyzed. A logistic regression analysis was performed to detect independent risk factors for PI. The cut-off value, sensitivity and specificity of these independent factors were calculated by receiver operating characteristic (ROC) curve.

RESULTS

In this study, 8.2% (35/426) of these patients were identified with PI. The average length of postoperative hospital stay was 12.54 ± 6.06 days in patients with PI compared with 8.91 ± 3.81 days in patients without PI (P =  0.001). These results indicated that surgical duration, PLIF approach, blood loss and length of postoperative diet restriction were potential risk factors for PI in patients with thoraco-lumbar spinal fusion surgery. The cut-off values of surgical duration, blood loss and length of postoperative diet restriction were 4.375 h, 750 ml and 9.5 h, respectively. Combination of surgical duration, PLIF approach, blood loss and length of postoperative diet restriction has the highest predictive value for PI (AUC = 0.910, P <  0.001).

CONCLUSION

Based on the study, surgical duration, PLIF approach, blood loss and length of postoperative diet restriction were the independent risk factors for PI in patients with posterior thoraco-lumbar spinal fusion surgery. Combined those factors has the highest risk for developing PI.

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.

Nonsteroidal anti-inflammatory drugs reduce the time to recovery of gut function after elective colorectal surgery: a systematic review and meta-analysis

AIM

Postoperative ileus causes significant patient morbidity after abdominal surgery. Some evidence suggests nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce time to gut recovery, but there has not been a meta-analysis to assess their efficacy. This systematic review and meta-analysis aimed to determine the benefit of NSAIDs for recovery of postoperative gut function in patients undergoing elective colorectal surgery.

METHOD

MEDLINE, EMBASE, CENTRAL and reference lists were searched with no date or language restrictions. Randomized controlled trials comparing the use of NSAIDs with placebo in the perioperative or postoperative period were identified. Included studies reported outcomes relevant to gut function: time to pass flatus or stool and time to tolerate an oral diet. The mean difference in time from surgery until passage of flatus, stool and tolerance of diet were meta-analysed using a random-effects model in RevMan 5.3.

RESULTS

This study identified 992 relevant articles. Five randomized controlled trials on patients undergoing elective colorectal surgery met our inclusion criteria and were meta-analysed. Compared with placebo, NSAIDs significantly improved the time to pass flatus (mean difference -9.44 h, 95% CI: -17.22, -1.65, I² = 70%, P = 0.02), time to pass stool (mean difference -12.09 h, 95% CI: -17.16, -7.02, I² = 0%, P < 0.001) and time to tolerate a diet (mean difference -11.95 h, 95% CI: -18.66, -5.24, I² = 0%, P < 0.001).

CONCLUSION

NSAIDs significantly improve time to gut recovery after elective colorectal surgery. Current evidence is not adequate to identify whether selective or nonselective drugs should be recommended. Further high-power studies using selective drugs are required.

Postoperative mechanical bowel obstruction after pharyngolaryngectomy for hypopharyngeal cancer: Retrospective analysis using a Japanese inpatient database

BACKGROUND

Data have been limited on donor-site mechanical bowel obstruction after pharyngolaryngectomy with free jejunum graft reconstruction.

METHODS

Using a nationwide Japanese inpatient database, we extracted data on patients who underwent pharyngolaryngectomy for hypopharyngeal cancer between July 2007 and March 2014. A Cox proportional hazard model was used to determine the association between background characteristics and the occurrence of mechanical bowel obstruction.

RESULTS

Among the 3320 eligible patients from 332 hospitals, 108 patients (3.3%) developed mechanical bowel obstruction after a median 88 (interquartile range 26-217) postoperative days. Multivariable Cox regression analysis revealed that older age (≥60 years old) was independently associated with an increased risk of mechanical bowel obstruction, whereas sex, body mass index [BMI], smoking status, comorbidity at admission, blood transfusion, history of surgery, and hospital type were not.

CONCLUSION

In pharyngolaryngectomy, careful attention should be paid to the risk of abdominal complications and, thus, to the graft choice, especially in elderly patients.

Perioperative Factors Predicting Prolonged Postoperative Ileus After Major Abdominal Surgery

BACKGROUND

Prolonged postoperative ileus (PPOI) is among the common complications adversely affecting postoperative outcomes. Predictors of PPOI after major abdominal surgery remain unclear, although various PPOI predictors have been reported in patients undergoing colorectal surgery. This study aimed to devise a model for stratifying the probability of PPOI in patients undergoing abdominal surgery.

METHODS

Between 2012 and 2013, 841 patients underwent major abdominal surgery after excluding patients who underwent less-invasive abdominal surgery, ileus-associated surgery, and emergency surgery. Postoperative managements were generally based on enhanced recovery after surgery (ERAS) program. The definition of PPOI was based on nausea, no oral diet, flatus absence, abdominal distension, and radiographic findings. A nomogram was devised by evaluating predictive factors for PPOI.

RESULTS

Of the 841 patients, 73 (8.8%) developed PPOI. Multivariable logistic regression analysis revealed smoking history (P = 0.025), colorectal surgery (P = 0.004), and an open surgical approach (P = 0.002) to all be independent predictive factors for PPOI. A nomogram was devised by employing these three significant predictive factors. The prediction model showed relatively good discrimination performance, the concordance index of which was 0.71 (95%CI 0.66-0.77). The probability of PPOI in patients with a smoking history who underwent open colorectal surgery was calculated to be 19.6%.

CONCLUSIONS

Colorectal surgery, open abdominal surgery, and smoking history were found to be independent predictive factors for PPOI in patients who underwent major abdominal surgery. A nomogram based on these factors was shown to be useful for identifying patients with a high probability of developing PPOI.

Zusanli (ST36) Acupoint Injection with Neostigmine for Paralytic Postoperative Ileus following Radical Gastrectomy for Gastric Cancer: a Randomized Clinical Trial

Background: The Zusanli (ST36) acupoint has been associated with treatment of various gastrointestinal conditions. There have been no studies of acupuncture therapy for paralytic postoperative ileus (PPOI). Materials and methods: Patients with PPOI following gastrectomy for gastric cancer were randomized to receive ST36 acupoint injection with neostigmine, gluteal intramuscular injection with 1.0 mg neostigmine, ST36 acupuncture alone, or standard therapy. The main outcome was the effectiveness rate for recovery of peristalsis. Secondary outcomes were time to bowel sound recovery, time to first flatus, and time to first defecation. Tertiary outcomes were drug-related adverse events, including abdominal pain, diarrhea, nausea, vomiting, tearing, delirium, seizure, and anxiety. Results: ST36 acupoint injection with neostigmine and gluteal intramuscular injection of neostigmine gave a higher rate of peristalsis recovery, and the ST36 acupoint injection group showed significantly higher total effectiveness rate than that of the intramuscular injection group. These interventions gave significantly shorter times to bowel sound recovery, shorter times to first flatus and first defecation compared with ST36 acupuncture and standard post-operative therapy (P < 0.01). ST36 acupoint injection group gave shorter time to bowel sound recovery, shorter time to first flatus and first defecation than those of the intramuscular injection group (P < 0.01). Drug-related adverse events in the intramuscular injection group were more serious than in the ST36 acupoint injection group (P < 0.05). Conclusion: ST36 acupoint injection with neostigmine is safe and effective for treatment of PPOI.

GENETIC TRIGGERS AND NEUROHUMORAL MESSENGERS OF POSTOPERATIVE INTESTINAL PARESIS, ITS VALUE IN PREDICTION, PREVENTION AND TREATMENT

The aim of research: to study the causes and mechanisms of postoperative intestinal paresis on the base of assessment of genetic determinism of neurohormonal processes which regulate the contractile ability of the intestines, to determine their role for the choice of treatment tactics. The study presents data about connection between variants of SERT gene, which regulates the reuptake of serotonin, and its concentration in blood plasma and the probability of occurrence of postoperative intestinal paresis. This made it possible not only to predict the occurrence of postoperative disorders of motor-evacuation function of the intestines, but also to improve the algorithms of prevention and pathogenetic based treatment.