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Murtaza R, Clarke O, Sivakanthan T, Al-Sarireh H, Al-Sarireh A, Raza MM, Navid AZ, Ali B, Hajibandeh S, Hajibandeh S. Effect of Alvimopan on Postoperative Ileus and Length of Hospital Stay in Patients Undergoing Bowel Resection: A Systematic Review and Meta-Analysis. Am Surg 2024; 90:3272-3283. [PMID: 39031053 DOI: 10.1177/00031348241265149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2024]
Abstract
AIMS The aim is to investigate the effect of alvimopan on postoperative ileus and length of hospital stay in patients undergoing bowel resection. METHODS The PRISMA statement standards were followed to conduct a systematic review and meta-analysis. The available literature was searched to identify all studies comparing alvimopan with no alvimopan in patients undergoing bowel resection. Postoperative ileus and length of hospital stay were the primary outcomes, and time to first bowel motion was the secondary outcome. Random-effects modeling was applied for analyses. RESULTS Analysis of 94 833 patients from 26 studies showed that alvimopan was associated with lower risk of postoperative ileus (OR: .57, 95% CI .48 to .67, P <.00001; high GRADE certainty), shorter length of hospital stay (MD: -1.08 day, 95% CI -1.36 to -.81, P < .00001; moderate GRADE certainty), and shorter time to first bowel motion (MD: -.43 day, 95% CI -.58 to -.28, P < .00001; moderate GRADE certainty). Separate analyses of randomized controlled trials and observational studies showed similar findings. Subgroup analyses suggested consistent findings in patients undergoing elective bowel resection, emergency bowel resection, and open surgery; however, alvimopan did not improve the outcomes in patients undergoing minimally invasive surgery. CONCLUSION Robust evidence supports the routine use of alvimopan in patients undergoing open bowel resection as indicated by lower risk of postoperative ileus and shorter length of hospital stay. We support incorporation of alvimopan into enhanced recovery after surgery programs for the procedures involving open bowel resection. The role of alvimopan in minimally invasive bowel resection needs more research.
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Affiliation(s)
- Rashid Murtaza
- Department of General Surgery, Royal Gwent Hospital, Newport, UK
| | - Olivia Clarke
- Department of General Surgery, University Hospital of Wales, Cardiff, UK
| | | | | | | | | | - Ahmad Zia Navid
- Department of General Surgery, Royal Shrewsbury Hospital, Shrewsbury, UK
| | - Baqar Ali
- Department of General Surgery, Royal Oldham Hospital, Oldham, UK
| | - Shahin Hajibandeh
- Department of General surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
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2
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Adesanya O, Bowler N, Tafuri S, Cruz-Bendezu A, Whalen MJ. Advances in Bowel Preparation and Antimicrobial Prophylaxis for Open and Laparoscopic Urologic Surgery. Urol Clin North Am 2024; 51:445-465. [PMID: 39349013 DOI: 10.1016/j.ucl.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/02/2024]
Abstract
Surgical site infections (SSIs) represent a major source of postoperative complications adversely impacting morbidity and mortality indices in surgical care. The discovery of antibiotics in the mid-20th century, and their ensuing use for preoperative antimicrobial bowel preparation and prophylaxis, drastically reduced the occurrence of SSIs providing a major tool to surgeons of various specialties, including urology. Because, the appropriate use of these antimicrobials is critical for their continued safety and efficacy, an understanding of the recommendations guiding their application is essential for all surgeons. Here, we comprehensively review these recommendations with a focus on open and laparoscopic urologic surgeries.
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Affiliation(s)
- Oluwafolajimi Adesanya
- Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD 21287-2101, USA
| | - Nick Bowler
- Department of Urology, George Washington University Hospital, Washington, DC 20037, USA
| | - Sean Tafuri
- Department of Urology, George Washington University Hospital, Washington, DC 20037, USA
| | - Alanna Cruz-Bendezu
- Department of Urology, George Washington University Hospital, Washington, DC 20037, USA
| | - Michael J Whalen
- Department of Urology, George Washington University School of Medicine, Washington, DC 20037, USA.
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Azuma Y, Koike K, Chiba H, Mitamura A, Tsuji H, Kawasaki S, Yokota T, Kanemasa T, Morioka Y, Suzuki T, Fujita M. Efficacy of Naldemedine on Intestinal Hypomotility and Adhesions in Rodent Models of Postoperative Ileus. Biol Pharm Bull 2023; 46:1714-1719. [PMID: 37853612 DOI: 10.1248/bpb.b23-00449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
Postoperative ileus (POI) often decreases patients' QOL because of prolonged hospitalization and readmission. Alvimopan, a peripheral μ-opioid receptor antagonist, is currently the only therapeutic drug for POI. The aim of this study was to examine the efficacy of naldemedine (a peripheral μ-opioid receptor antagonist with a non-competitive pharmacological profile different from that of alvimopan) on postoperative intestinal hypomotility and adhesion in rodent models, and compare it with the effects of alvimopan. Oral administration of naldemedine (0.3 mg/kg) and alvimopan (3 mg/kg) significantly inhibited the decrease in intestinal motility induced by mechanical irritation in mice (p < 0.01, for both). Naldemedine (1 mg/kg) significantly shortened the adhesion length in chemical-induced postoperative adhesion model rats (p < 0.05). Alvimopan (3 mg/kg) also significantly reduced the adhesion ratio (p < 0.01). These findings suggest that naldemedine is effective for postoperative intestinal hypomotility and adhesions in rodents (i.e., as for alvimopan). Thus, naldemedine may be a useful option for the treatment of POI.
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Affiliation(s)
- Yuki Azuma
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd
| | - Katsumi Koike
- Laboratory for Drug Discovery and Disease Research, Shionogi & Co., Ltd
| | - Hiroki Chiba
- Research Area for Drug Candidate Generation II, Shionogi TechnoAdvance Research Co., Ltd
| | - Aki Mitamura
- Corporate Planning Division, Shionogi TechnoAdvance Research Co., Ltd
| | - Hiroki Tsuji
- Research Area for Drug Candidate Generation II, Shionogi TechnoAdvance Research Co., Ltd
| | - Sachiko Kawasaki
- Research Area for Drug Candidate Generation I, Shionogi TechnoAdvance Research Co., Ltd
| | | | | | | | - Tsutomu Suzuki
- Department of Pharmacology, School of Pharmacy, Shonan University of Medical Sciences
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Hendrickson NR, Zhang Y, Amoafo L, Randell Z, Rasmussen M, Zeidan M, Shorten P, Brodke DS, Spina N, Lawrence BD, Spiker WR. Risk Factors for Postoperative Ileus in Patients Undergoing Spine Surgery. Global Spine J 2023; 13:2176-2181. [PMID: 35129418 PMCID: PMC10538340 DOI: 10.1177/21925682221075056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective Cohort Study. OBJECTIVES Postoperative ileus (POI) is a common complication following elective spinal surgeries. The aim of this study was to determine the incidence of POI and identify demographic and surgical risk factors for developing POI after elective instrumented fusion of the thoracolumbar spine. METHODS The University of Utah Institutional Review Board (IRB) approved this retrospective study. The study does not require informed consent given the data reviewed was deidentified and collected in accordance with the institution's standard of care. A designated IRB committee determined that study is exempt under exemption category 7. IRB approval number 00069703. Patients undergoing instrumented thoracolumbar fusion for one or more levels were retrospectively identified from an internal spine surgery database. Cases performed for trauma, infection, or tumors were excluded. Demographics, medical comorbidities, surgical variables, and opioid medication administration (morphine milligram equivalents, MME) were abstracted from the electronic medical record. Univariate analysis was used to identify variables associated with POI. These variables were then tested for independent association with POI using multivariate logistic regression. RESULTS 418 patients were included in the current study. The incidence of POI was 9.3% in this cohort. There was no significant relationship between development of POI and patient age, gender, BMI, diabetes mellitus, thyroid dysfunction, lung disease, CKD, GERD, smoking status, alcohol abuse, anemia, or prior abdominal surgery. Univariate analysis demonstrated significant association between POI and fusion ≥7 levels compared to fusions of fewer levels (P = .001), as well as intraoperative sufentanil compared to other opioids (35.9% vs 20.1%, P = .02). POI was not significantly associated with total intraoperative MME, approach, use of interbody cage, or osteotomy. Multivariate logistic regression confirmed total 24-hour postoperative MME as an independent risk factor for POI (OR 1.004, P = .04), however, intraoperative sufentanil administration was not an independent risk factor for POI when controlling for other variables. CONCLUSIONS This retrospective cohort study demonstrates that greater postoperative MME is an independent risk factor for POI after thoracolumbar spine fusion when accounting for demographic, medical, and surgical variables with multiple logistic regression. Prospective studies are warranted to evaluate clinical measures to decrease the risk of POI among patients undergoing instrumented thoracolumbar spinal fusions.
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Affiliation(s)
| | - Yue Zhang
- Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Linda Amoafo
- Population Health Sciences, University of Utah, Salt Lake City, UT, USA
| | - Zane Randell
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Michaela Rasmussen
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Michelle Zeidan
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Pete Shorten
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Darrel S. Brodke
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Nicholas Spina
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Brandon D. Lawrence
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - W. Ryan Spiker
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
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Greco CD, Petro CC, Thomas JD, Montelione K, Tu C, Fafaj A, Zolin S, Krpata D, Rosenblatt S, Rosen M, Beffa L, Prabhu A. Ileus rate after abdominal wall reconstruction: a retrospective analysis of two clinical trials. Hernia 2022; 26:1591-1598. [PMID: 36319900 DOI: 10.1007/s10029-022-02687-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 09/14/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Postoperative ileus (POI) is the paralytic disruption of gastrointestinal motility, a common complication following abdominal wall reconstruction that often leads to increased patient morbidity and length of stay (LOS). We reviewed two randomized clinical trials to determine POI rates, predictive factors, LOS, and associated cost. METHODS Two randomized trials were performed from 2017-2019 with all patients receiving elective open abdominal wall reconstruction with retromuscular mesh. Using multivariate logistic regression, we performed a retrospective analysis including demographics and operative details from patients at a single site to determine predictive factors for POI. All medical costs encompassing surgery and the 30-day postoperative period were compared between ileus and non-ileus groups. RESULTS Four hundred and seventy patients were reviewed with a POI rate of 13.0% (N = 61). There were no differences in age, body mass index (BMI), history of abdominal surgery, or comorbidities between patients with and without POI. Logistic regression showed no association with POI and age, BMI, hernia width, or operative time lasting longer than 4 h. Median LOS was 8 days for patients with POI compared to five for those without (p < 0.001). Relative median 30-day costs were 1.19 in patients with ileus and 1.0 in those without (p < 0.001). CONCLUSION We identified a 13% rate of POI in patients undergoing open abdominal wall reconstruction with mesh with no clearly identified predisposing factors. This resulted in a 3 days increase in median LOS and 19% additional costs. Further efforts should be devoted to investigating interventions that may reduce postoperative ileus after abdominal wall reconstruction.
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Affiliation(s)
- C D Greco
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - C C Petro
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - J D Thomas
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - K Montelione
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - C Tu
- Quantitative Health Science, Cleveland Clinic, Cleveland, OH, USA
| | - A Fafaj
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - S Zolin
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - D Krpata
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - S Rosenblatt
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - M Rosen
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - L Beffa
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - A Prabhu
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA.
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Positive Patient Postoperative Outcomes with Pharmacotherapy: A Narrative Review including Perioperative-Specialty Pharmacist Interviews. J Clin Med 2022; 11:jcm11195628. [PMID: 36233497 PMCID: PMC9572852 DOI: 10.3390/jcm11195628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/15/2022] [Accepted: 09/21/2022] [Indexed: 11/19/2022] Open
Abstract
The influence of pharmacotherapy regimens on surgical patient outcomes is increasingly appreciated in the era of enhanced recovery protocols and institutional focus on reducing postoperative complications. Specifics related to medication selection, dosing, frequency of administration, and duration of therapy are evolving to optimize pharmacotherapeutic regimens for many enhanced recovery protocolized elements. This review provides a summary of recent pharmacotherapeutic strategies, including those configured within electronic health record (EHR) applications and functionalities, that are associated with the minimization of the frequency and severity of postoperative complications (POCs), shortened hospital length of stay (LOS), reduced readmission rates, and cost or revenue impacts. Further, it will highlight preventive pharmacotherapy regimens that are correlated with improved patient preparation, especially those related to surgical site infection (SSI), venous thromboembolism (VTE), nausea and vomiting (PONV), postoperative ileus (POI), and emergence delirium (PoD) as well as less commonly encountered POCs such as acute kidney injury (AKI) and atrial fibrillation (AF). The importance of interprofessional collaboration in all periprocedural phases, focusing on medication management through shared responsibilities for drug therapy outcomes, will be emphasized. Finally, examples of collaborative care through shared mental models of drug stewardship and non-medical practice agreements to improve operative throughput, reduce operative stress, and increase patient satisfaction are illustrated.
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Zheng H, Liu Y, Chen Z, Sun Y, Xu J. Novel nomogram for predicting risk of early postoperative small bowel obstruction after right colectomy for cancer. World J Surg Oncol 2022; 20:19. [PMID: 35062961 PMCID: PMC8783471 DOI: 10.1186/s12957-022-02489-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/08/2022] [Indexed: 12/16/2022] Open
Abstract
Background Early postoperative small bowel obstruction (EPSBO) is a common complication after colorectal cancer surgery. Few studies have specifically studied risk factors for early small bowel obstruction after right colectomy, especially in establishing predictive models. The purpose of the current study was to establish an effective nomogram to predict the incidence of EPSBO after right colectomy. Methods The current study retrospectively analyzed data from a total of 424 patients who underwent right colectomy in a local hospital from January 2014 to March 2021. A logistic regression model was used to identify potential risk factors for EPSBO after right colectomy. A nomogram was established by independent risk factors, and the prediction performance of the model was evaluated using an area under the receiver operating characteristic (ROC) curve and calibration chart. Results A total of 45 patients (10.6%) developed early small bowel obstruction after right colectomy. Male sex, history of abdominal surgery, open surgery, long operative time, anastomotic leakage, and preoperative albumin were closely related to EPSBO. Analysis of postoperative rehabilitation indices showed that EPSBO remarkably slowed the postoperative rehabilitation speed of patients. Multivariate logistic regression analysis showed that male sex, open surgery, operative time, and anastomotic leakage were independent risk factors (P < 0.05), and the operation time had the greatest impact on EPSBO. On the basis of multivariate logistic regression, a nomogram was constructed, which showed moderate accuracy in predicting EPSBO, with a C-statistic of 0.716. The calibration chart showed good consistency between the predicted probability and ideal probability. Conclusion The current study constructed a nomogram based on the clinical data of patients who underwent right colectomy, which had moderate predictability and could provide reference value for clinicians to evaluate the risk of EPSBO.
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Shao JK, Liu Q, Pei W, Wang Y, Yang NN, Qi LY, Huang J, Yang JW, Liu CZ. Electroacupuncture for postoperative ileus after laparoscopic surgery on colorectal cancer: study protocol for a randomized controlled trial. Trials 2021; 22:610. [PMID: 34503565 PMCID: PMC8428035 DOI: 10.1186/s13063-021-05564-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 08/24/2021] [Indexed: 01/24/2023] Open
Abstract
Background Postoperative ileus (POI) occurs in almost all patients after abdominal laparoscopic surgery, resulting in complications and increasing the length of hospitalization. Electroacupuncture has been used as an alternative therapy for gastrointestinal dysfunction, but its efficacy for POI is inconclusive. The study is designed to determine whether electroacupuncture can accelerate recovery from POI. Methods/design This study is a three-arm, randomized controlled trial. A total of 105 patients will be randomized into a group receiving electroacupuncture at Tianshu (ST25), a group receiving electroacupuncture at Zusanli (ST36), or a control group in a 1:1:1 ratio. Patients in the electroacupuncture groups will receive electroacupuncture treatment for 4 days from the first day after surgery. The primary outcome consists of the time to first flatus and the time to first defecation. Secondary outcomes include the time to first tolerance of liquid and semiliquid food; the length of the hospital stay; postoperative pain, nausea, and vomiting; abdominal distension; the time to first get out of bed; and postoperative complications. The outcomes will be assessed by the patients themselves every day during hospitalization. Surgeons, nurses, assessors, and statisticians will be blinded to the group assignments. Patients in the two electroacupuncture groups, but not in the control group, will be blinded to the group assignments. The acupuncturists will not be blinded. Discussion The aim of this trial is to provide a nonpharmacological therapy for POI and may provide evidence of the effect of electroacupuncture at ST25 or ST36 on POI. Trial registration Chinese Clinical Trial Registry ChiCTR1900027466. Registered on 14 November 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05564-3.
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Affiliation(s)
- Jia-Kai Shao
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Qian Liu
- Department of Colorectal Surgery, Chinese Academy of Medical Sciences Cancer Institute and Hospital, Beijing, China
| | - Wei Pei
- Department of Colorectal Surgery, Chinese Academy of Medical Sciences Cancer Institute and Hospital, Beijing, China
| | - Yu Wang
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Na-Na Yang
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Ling-Yu Qi
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Jin Huang
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
| | - Jing-Wen Yang
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China.
| | - Cun-Zhi Liu
- International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, No. 11, Bei San Huan Dong Lu, Chaoyang District, Beijing, 100029, China
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McKechnie T, Anpalagan T, Ichhpuniani S, Lee Y, Ramji K, Eskicioglu C. Selective Opioid Antagonists Following Bowel Resection for Prevention of Postoperative Ileus: a Systematic Review and Meta-analysis. J Gastrointest Surg 2021; 25:1601-1624. [PMID: 33768428 DOI: 10.1007/s11605-021-04973-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/03/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative ileus (POI) remains a common complication following bowel resection. Selective opioid antagonists have been increasingly studied as prophylactic pharmaceutical aids to reduce rates of POI. The aim of this study was to evaluate the impact of selective opioid antagonists on return of bowel function following bowel resection. METHODS MEDLINE, Embase, and CENTRAL were systematically searched. Articles were included if they compared the incidence of POI and/or length of stay (LOS) in patients receiving and not receiving selective opioid antagonists following elective bowel resection. A pairwise meta-analyses using inverse variance random effects was performed. RESULTS From 636 citations, 30 studies with 45,051 patients receiving selective opioid antagonists (51.3% female, mean age: 60.9) and 55,071 patients not receiving selective opioid antagonists (51.2% female, mean age: 61.1) were included. Patients receiving selective opioid antagonists had a significantly lower rate of POI (10.1% vs. 13.8%, RR 0.68, 95%CI 0.63-0.75, p < 0.01). Selective opioid antagonists also significantly reduced LOS (MD - 1.08, 95%CI - 1.47 to - 0.69, p < 0.01), readmission (RR 0.94, 95%CI 0.89-0.99, p = 0.03), and 30-day morbidity (RR 0.85, 95%CI 0.79-0.90, p < 0.01). Improvements in LOS, readmission rate, and morbidity were not significant when analysis was limited to laparoscopic surgery. There was no significant difference in inpatient healthcare costs (SMD - 0.33, 95%CI - 0.71-0.04, p = 0.08). CONCLUSIONS Rate of POI decreases with the use of selective opioid antagonists in patients undergoing bowel resection. Selective opioid antagonists also improve LOS, rates of readmission, and 30-day morbidity for patients undergoing open bowel resection. Addition of these medications to enhance recovery after surgery protocols should be considered.
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Affiliation(s)
- Tyler McKechnie
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Tharani Anpalagan
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Yung Lee
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Karim Ramji
- Division of General Surgery, Department of Surgery, St. Joseph Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, Ontario, L8N 4A6, Canada
| | - Cagla Eskicioglu
- Division of General Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada.
- Division of General Surgery, Department of Surgery, St. Joseph Healthcare, 50 Charlton Avenue East Hamilton, Hamilton, Ontario, L8N 4A6, Canada.
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Comparison of treatment to improve gastrointestinal functions after colorectal surgery within enhanced recovery programmes: a systematic review and meta-analysis. Sci Rep 2021; 11:7423. [PMID: 33795783 PMCID: PMC8016851 DOI: 10.1038/s41598-021-86699-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 03/10/2021] [Indexed: 02/01/2023] Open
Abstract
Despite a significant improvement with enhanced recovery programmes (ERP), gastro-intestinal (GI) functions that are impaired after colorectal resection and postoperative ileus (POI) remain a significant issue. In the literature, there is little evidence of the distinction between the treatment assessed within or outside ERP. The purpose was to evaluate the efficiency of treatments to reduce POI and improve GI function recovery within ERP. A search was performed in PubMed and Scopus on 20 September 2019. The studies were included if they compared the effect of the administration of a treatment aiming to treat or prevent POI or improve the early functional outcomes of colorectal surgery within an ERP. The main outcome measures were the occurrence of postoperative ileus, time to first flatus and time to first bowel movement. Treatments that were assessed at least three times were included in a meta-analysis. Among the analysed studies, 28 met the eligibility criteria. Six of them focused on chewing-gum and were only randomized controlled trials (RCT) and 8 of them focused on Alvimopan but none of them were RCT. The other measures were assessed in less than 3 studies over RCTs (n = 11) or retrospective studies (n = 2). In the meta-analysis, chewing gum had no significant effect on the endpoints and Alvimopan allowed a significant reduction of the occurrence of POI. Chewing-gum was not effective on GI function recovery in ERP but Alvimopan and the other measures were not sufficiently studies to draw conclusion. Randomised controlled trials are needed.Systematic review registration number CRD42020167339.
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Alhashemi M, Hamad R, El-Kefraoui C, Blouin MC, Amar-Zifkin A, Landry T, Lee L, Baldini G, Feldman LS, Fiore JF. The association of alvimopan treatment with postoperative outcomes after abdominal surgery: A systematic review across different surgical procedures and contexts of perioperative care. Surgery 2020; 169:934-944. [PMID: 33380353 DOI: 10.1016/j.surg.2020.11.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/13/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Alvimopan is a Food and Drug Administration-approved treatment to accelerate gastrointestinal recovery after abdominal surgery; however, benefits may vary across different procedures and contexts of care. The purpose of this study is to summarize the evidence regarding the effect of alvimopan on postoperative outcomes after abdominal surgery. METHODS Major databases (Medline, Embase, Biosis, Cochrane, Web of Science, and Scopus) were searched for randomized controlled trials and nonrandomized studies comparing alvimopan versus control. Risk of bias was assessed using Cochrane's risk of bias tool 2.0 (for randomized controlled trials) and Risk of Bias in Nonrandomized Studies-of Intervention tool (for nonrandomized studies). Results were appraised descriptively as heterogeneity in reporting and risk of bias hindered meta-analysis. Quality of evidence across different surgical procedures and contexts of care (ie, open versus minimally invasive surgery, traditional care versus enhanced recovery pathway) was evaluated using Grading of Recommendations Assessment, Development, and Evaluation. RESULTS Nine randomized controlled trials and 35 nonrandomized studies were identified. Evidence of low to moderate certainty supports that alvimopan reduces length of stay and improves gastrointestinal recovery after open bowel resection and open radical cystectomy. Limited evidence supports alvimopan for surgeries not listed in Food and Drug Administration labels (ie, total abdominal hysterectomy and retroperitoneal lymph node dissection). Similar effects were observed in traditional and enhanced recovery pathway settings, but enhanced recovery pathway elements varied across studies. There is very low certainty of evidence supporting alvimopan for patients undergoing minimally invasive surgery. CONCLUSION Evidence supports that alvimopan improves outcomes after open bowel resection and open radical cystectomy. Benefits for patients undergoing minimally invasive surgery and treated in contemporary enhanced recovery pathway settings remain uncertain. These findings contribute important new knowledge to inform evidence-based alvimopan prescribing.
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Affiliation(s)
- Mohsen Alhashemi
- Department of Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, QC, Canada
| | - Raphael Hamad
- Department of Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, QC, Canada
| | - Charbel El-Kefraoui
- Department of Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Mathieu C Blouin
- Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, QC, Canada
| | | | - Tara Landry
- Medical Libraries, McGill University Health Centre, Montreal, QC, Canada
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Gabriele Baldini
- Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Liane S Feldman
- Department of Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Julio F Fiore
- Department of Surgery, McGill University, Montreal, QC, Canada; Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University, Montreal, QC, Canada; Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
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12
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Ueland W, Walsh-Blackmore S, Nisiewicz M, Davenport DL, Plymale MA, Plymale M, Roth JS. The contribution of specific enhanced recovery after surgery (ERAS) protocol elements to reduced length of hospital stay after ventral hernia repair. Surg Endosc 2020; 34:4638-4644. [PMID: 31705287 DOI: 10.1007/s00464-019-07233-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 10/28/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Ventral hernia repair (VHR) is a commonly performed procedure that may be associated with prolonged hospitalization. Enhanced recovery after surgery (ERAS) protocols are intended to decrease hospital length of stay (LOS) and improve outcomes. This study evaluated the impact of compliance with individual VHR ERAS elements on LOS. METHODS With IRB approval, a medical record review (perioperative characteristics, clinical outcomes, compliance with ERAS elements) was conducted of open VHR consecutive cases performed in August 2013-July 2017. The ERAS protocol was implemented in August 2015; elements in place prior to implementation were accounted for in compliance review. Clinical predictors of LOS were determined through forward regression of log-transformed LOS. The effects of specific ERAS elements on LOS were assessed by adding them to the model in the presence of the clinical predictors. RESULTS Two-hundred and thirty-four patients underwent VHR (109 ERAS, 125 pre-ERAS). Across all patients, the mean LOS was 5.4 days (SD = 3.3). Independent perioperative predictors (P's < 0.05) of increased LOS were CDC Wound Class III/IV (38% increase above the mean), COPD (35%), prior infected mesh (21%), concomitant procedure (14%), mesh size (3% per 100 cm2), and age (8% increase per 10 years from mean age). Formal ERAS implementation was associated with a 15% or about 0.7 days (95% CI 6%-24%) reduction in mean LOS after adjustment. Compliance with acceleration of intestinal recovery was low (25.6%) as many patients were not eligible for alvimopan use due to preoperative opioids, yet when achieved, provided the greatest reduction in LOS (- 36%). CONCLUSIONS Implementation of an ERAS protocol for VHR results in decreased hospital LOS. Evaluation of the impact of specific ERAS element compliance to LOS is unique to this study. Compliance with acceleration of intestinal recovery, early postoperative mobilization, and multimodal pain management standards provided the greatest LOS reduction.
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Affiliation(s)
- Walker Ueland
- University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | | | | | | | - John S Roth
- Division of General Surgery, University of Kentucky, Lexington, KY, USA. .,Division of General Surgery, Department of Surgery, University of Kentucky, C 222, Chandler Medical Center, 800 Rose Street, Lexington, KY, 40536, USA.
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13
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Bartolini I, Risaliti M, Ringressi MN, Melli F, Nannini G, Amedei A, Muiesan P, Taddei A. Role of gut microbiota-immunity axis in patients undergoing surgery for colorectal cancer: Focus on short and long-term outcomes. World J Gastroenterol 2020; 26:2498-2513. [PMID: 32523307 PMCID: PMC7265137 DOI: 10.3748/wjg.v26.i20.2498] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/27/2020] [Accepted: 05/13/2020] [Indexed: 02/06/2023] Open
Abstract
Human body is colonized by a huge amount of microorganisms mostly located in the gastrointestinal tract. These dynamic communities, the environment and their metabolites constitute the microbiota. Growing data suggests a causal role of a dysbiotic microbiota in several pathologies, such as metabolic and neurological disorders, immunity dysregulations and cancer, especially the well-studied colorectal cancer development. However, many were preclinical studies and a complete knowledge of the pathogenetic mechanisms in humans is still absent. The gut microbiota can exert direct or indirect effects in different phases of colorectal cancer genesis. For example, Fusobacterium nucleatum promotes cancer through cellular proliferation and some strains of Escherichia coli and Bacteroides fragilis produce genotoxins. However, dysbiosis may also cause a pro-inflammatory state and the stimulation of a Th17 response with IL-17 and IL-22 secretion that have a pro-oncogenic activity, as demonstrated for Fusobacterium nucleatum. Microbiota has a crucial role in several stages of postoperative course; dysbiosis in fact seems related with surgical site infections and Enterococcus faecalis (and other collagenase-producers microbes) are suggested as a cause of anastomotic leak. Consequently, unbalanced presence of some species, together with altered immune response may also have a prognostic role. Microbiota has also a substantial role in effectiveness of chemotherapy, chemoresistance and in the related side effects. In other words, a complete knowledge of the fine pathological mechanisms of gut microbiota may provide a wide range of new diagnostic tools other than therapeutic targets in the light of tailored medicine.
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Affiliation(s)
- Ilenia Bartolini
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Matteo Risaliti
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Maria Novella Ringressi
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Filippo Melli
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Giulia Nannini
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Amedeo Amedei
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Paolo Muiesan
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
| | - Antonio Taddei
- Department of Experimental and Clinical Medicine, University of Florence, Florence 50134, Italy
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14
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Liska D, Bora Cengiz T, Novello M, Aiello A, Stocchi L, Hull TL, Steele SR, Delaney CP, Holubar SD. Do Patients With Inflammatory Bowel Disease Benefit from an Enhanced Recovery Pathway? Inflamm Bowel Dis 2020; 26:476-483. [PMID: 31372647 DOI: 10.1093/ibd/izz172] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery pathways (ERPs) have been shown to reduce length of stay (LOS), complications, and costs after colorectal surgery; yet, little data exists regarding patients with inflammatory bowel disease (IBD). We hypothesized that implementation of ERP for IBD patients is associated with shorter LOS and improved economic outcomes. METHODS An IRB-approved prospective clinical database was used to identify consecutive patients from 2015 to 2017. Patients were grouped as "pre-ERP" and "post-ERP" based on the date of implementation of a comprehensive ERP. Ileostomy closures, redo pouch operations, and outpatient operations were excluded. The relationship between ERP, LOS, and secondary outcomes was assessed using univariate and multivariate analysis. RESULTS Overall, a total of 671 patients were included: 345 (51.4%) with Crohn's disease (CD) and 326 (48.6%) with ulcerative colitis (UC). Of these, 425 were pre-ERP (63.4%), and 246 were post-ERP (36.6%). The groups did not differ in terms of age, gender, American Society of Anesthesiologist (ASA) scores, comorbidities, estimated blood loss, or ostomy construction. The post-ERP group had a significantly higher mean body mass index (BMI), more patients with CD, longer operative time, and more minimally invasive surgery (MIS; all P < 0.05). The post-ERP group had a significantly shorter LOS (6 vs 4.5 days, median), whereas mean hospital costs decreased by 15.7%. There was no difference in readmissions or complications. On multivariate analysis, MIS and ERP use were both associated with a shorter LOS. CONCLUSION Inflammatory bowel disease patients benefit from the use of ERP, demonstrating decreased LOS and costs without an increase in complications and readmissions. Enhanced recovery pathways should be routinely implemented in this often challenging patient population.
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Affiliation(s)
- David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Turgut Bora Cengiz
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Matteo Novello
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Alexandra Aiello
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Luca Stocchi
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
| | - Stefan D Holubar
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, OH, USA
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15
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Grass F, Lovely JK, Crippa J, Hübner M, Mathis KL, Larson DW. Potential Association Between Perioperative Fluid Management and Occurrence of Postoperative Ileus. Dis Colon Rectum 2020; 63:68-74. [PMID: 31633601 DOI: 10.1097/dcr.0000000000001522] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative ileus remains an issue after colorectal surgery delaying recovery and increasing the length of hospital stay and costs. OBJECTIVE The purpose of this study was to analyze the impact of perioperative fluid management on ileus occurrence after colorectal surgery within a fully implemented enhanced recovery pathway. DESIGN This was a retrospective cohort study of a prospectively maintained institutional database. SETTINGS The study was conducted at a tertiary academic facility with fully implemented standardized enhanced recovery pathway over the entire study period. PATIENTS All of the consecutive elective major colorectal resections for benign or malign indications between 2011 and 2016 were included. MAIN OUTCOME MEASURES Postoperative ileus was defined as the need for nasogastric tube reinsertion. Perioperative fluid management and surgical outcome were compared between patients presenting with ileus and those without. Potential risk factors for ileus were identified through multinomial logistic regression. RESULTS Postoperative ileus occurred in 377 (9%) of 4205 included patients at day 4 (interquartile range, 2-5 d). Intraoperatively, ileus patients received 3.2 ± 2.6 L of fluids, whereas the remaining patients received 2.5 ± 1.7 L (p < 0.001). Weight gain was 3.8 ± 7.1 kg in ileus patients versus 3.0 ± 6.6 kg (p = 0.272) in the remaining patients at postoperative day 1, 4.4 ± 6.5 kg versus 3.1 ± 7.0 kg (p = 0.028) at postoperative day 2, and 1.8 ± 6.0 kg versus 0.0 ± 6.0 kg at discharge (p = 0.002). The multivariable model including all significant (p < 0.05) demographic, fluid management-related, and surgical parameters retained postoperative day 0 fluids of >3 L (OR = 1.65 (95% CI, 1.13-2.41); p = 0.009), postoperative day 2 weight gain of >2.5 kg (OR = 1.49 (95% CI, 1.01-2.21); p = 0.048), and occurrence of postoperative complications (OR = 2.00 (95% CI, 1.39-2.90); p < 0.001) as independent risk factors for ileus. LIMITATIONS This study was limited by its retrospective design. Fluid management depends on patient-, disease-, and surgery-related factors and cannot be generalized and extrapolated. CONCLUSIONS Fluid overload and occurrence of postoperative complications were independent risk factors for postoperative ileus. This calls for action to keep perioperative fluids below suggested thresholds. See Video Abstract at http://links.lww.com/DCR/B54. ASOCIACIÓN POTENCIAL ENTRE EL MANEJO DEL LÍQUIDO PERIOPERATORIO Y EL SUCESO DE ÍLEO POSTOPERATORIO: El íleo postoperatorio sigue siendo un problema después de una cirugía colorrectal que retrasa la recuperación y aumenta la duración de la estancia hospitalaria y los costos.Analizar el impacto del manejo del líquido perioperatorio en la incidencia de íleo después de la cirugía colorrectal dentro de una vía de recuperación mejorada totalmente implementada.Estudio de cohorte retrospectivo de una base de datos institucional mantenida prospectivamente.Centro académico terciario con una ruta de recuperación mejorada estandarizada completamente implementada durante todo el período del estudio.Se incluyeron todas las resecciones colorrectales mayores electivas consecutivas para indicaciones benignas o malignas entre 2011 y 2016.El íleo postoperatorio se definió como la necesidad de reinserción de la sonda nasogástrica. El manejo del líquido perioperatorio y el resultado quirúrgico se compararon entre los pacientes con íleo y los que no. Los posibles factores de riesgo para el íleo se identificaron mediante regresión logística multinominal.El íleo postoperatorio se ocurrió en 377 (9%) de los 4205 pacientes incluidos al cuarto día (RIC 2-5). Intraoperatoriamente, los pacientes con íleo recibieron 3.2 ± 2.6 L de líquidos, mientras que los pacientes restantes recibieron 2.5 ± 1.7 L (p < 0.001). El aumento de peso fue de 3.8 ± 7.1 kg en pacientes con íleo versus 3 ± 6.6 kg (p = 0.272) en los pacientes restantes en el día postoperatorio 1, 4.4 ± 6.5 kg vs. 3.1 ± 7 kg (p = 0.028) en el día postoperatorio 2 y 1.8 ± 6 kg versus a 0 ± 6 kg al tiempo de alta hospitalaria (p = 0.002). El modelo multivariable que incluye todos los parámetros demográficos, del manejo de líquidos y quirúrgicos significativos (p <0.05) mantuvo líquidos del día 0 después de la operación de> 3L (proporción de probabilidad 1.65, intervalo de confianza del 95% 1.13-2.41, p = 0.009), ganancia de peso de > 2.5 kg en el dia postoperatorio 2 (proporción de probabilidad 1.49, 95% intervalo de confianza 1.01-2.21, p = 0.048) y aparición de complicaciones postoperatorias (proporción de probabilidad 2, 95% intervalo de confianza 1.39-2.9, p <0.001) como factores de riesgo independientes para íleo.Diseño retrospectivo. El manejo de líquidos depende de factores relacionados con el paciente, la enfermedad y la cirugía, y no puede generalizarse ni extrapolarse.La sobrecarga de líquidos y la aparición de complicaciones postoperatorias fueron factores de riesgo independientes para el íleo postoperatorio. Esto requiere medidas para mantener los líquidos perioperatorios por debajo de los umbrales sugeridos. Vea el Video del Resumen en http://links.lww.com/DCR/B54.
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Affiliation(s)
- Fabian Grass
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Visceral Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Jenna K Lovely
- Hospital Pharmacy Services, Mayo Clinic, Rochester, Minnesota
| | - Jacopo Crippa
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Kellie L Mathis
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
| | - David W Larson
- Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, Minnesota
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Sapci I, Hameed I, Ceylan A, Oktem A, Rencuzogullari A, Hull TL, Liska D, Delaney CP, Gorgun E. Predictors of ileus following colorectal resections. Am J Surg 2019; 219:527-529. [PMID: 31604485 DOI: 10.1016/j.amjsurg.2019.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 10/03/2019] [Accepted: 10/04/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND Ileus following colorectal surgery is a significant burden for healthcare and can be challenging to manage. This study aims to evaluate risk factors for postoperative ileus in patients undergoing colorectal surgery. METHODS Patients who underwent colorectal resections for any diagnosis were identified from our institutional database between 2009 and 2014. Patient demographics, pre-operative comorbidities, and operation-related variables were compared in patients with and without ileus within 30 days after surgery. RESULTS A total of 5369 patients were identified with a mean age of 53 years. 892 patients (16.6%) developed postoperative ileus. Males were twice as likely (p < 0.001) and patients with anastomosis were 1.4 times more likely to develop ileus compared to those without (p < 0.001). Laparoscopic surgery and younger age were associated with lower ileus risk. Patients with colorectal cancer, Crohn's disease, and ulcerative colitis diagnoses were all more likely to develop postoperative ileus compared to patients with diverticular disease. CONCLUSIONS Evaluation of factors such as male gender, older age, anastomosis formation, diagnosis of cancer and inflammatory bowel disease, can help facilitate earlier diagnosis of postoperative ileus and may require consideration of prophylactic therapy.
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Affiliation(s)
- Ipek Sapci
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Ohio, USA
| | - Irbaz Hameed
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Ohio, USA
| | - Arda Ceylan
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Ohio, USA
| | - Ayda Oktem
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Ohio, USA
| | - Ahmet Rencuzogullari
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Ohio, USA
| | - Tracy L Hull
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Ohio, USA
| | - David Liska
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Ohio, USA
| | - Conor P Delaney
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Ohio, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Ohio, USA.
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17
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Alvimopan is associated with decreased length of stay for both open and laparoscopic segmental colectomy. Surgery 2019; 166:483-488. [PMID: 31345565 DOI: 10.1016/j.surg.2019.04.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/19/2019] [Accepted: 03/06/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Alvimopan has been shown to reduce length of stay after bowel resection. Use remains variable among institutions due to cost and efficacy concerns in laparoscopic surgery. Additionally, alvimopan's effects have not been isolated from other medications within enhanced recovery protocols. The aim of this study was to distinguish the relationship between alvimopan use, length of stay, and cost in both open and laparoscopic segmental colectomies. METHODS The Vizient dataset was queried to identify patients undergoing open and laparoscopic colectomies from 2015 to 2017. Patient demographics and treatment details were collected. Primary outcomes of interest included duration of stay and total direct costs. RESULTS In the study, 12,727 patients met inclusion criteria and 3,358 (26.4%) received alvimopan. For both open and laparoscopic groups, alvimopan was associated with decreased length of stay in unadjusted (4.0 vs 6.0 days, P < .01 and 3.0 vs 4.0 days, P < .01, respectively) and adjusted analysis (effect ratio 0.79, P < .01 and 0.85, P < .01, respectively). Alvimopan was associated with a 7% decrease in direct cost after adjustment (effect ratio 0.93, P = .04), with no cost difference in laparoscopic procedures (effect ratio 0.99, P = .71). CONCLUSION Alvimopan use is associated with decreased length of stay for both open and laparoscopic colon resections, decreased cost in open procedures, and no cost difference for laparoscopic procedures.
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18
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Alvimopan Significantly Reduces Length of Stay and Costs Following Colorectal Resection and Ostomy Reversal Even Within an Enhanced Recovery Protocol. Dis Colon Rectum 2019; 62:755-761. [PMID: 30807457 DOI: 10.1097/dcr.0000000000001354] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Alvimopan accelerates GI recovery after colorectal resection. Data on real-world cost-effectiveness have been mixed. OBJECTIVE This study aimed to evaluate if adding alvimopan to an enhanced recovery pathway reduces length of stay. DESIGN Patients undergoing colorectal resection or ostomy reversal for the year before and after the introduction of alvimopan were evaluated. SETTING This study was conducted at a single academic medical center. PATIENTS Patients undergoing elective colorectal resection (488) or ostomy reversal (148) were included. MAIN OUTCOME MEASURES The primary outcomes measured were length of stay and prolonged length of stay defined as >75th percentile for each procedure. RESULTS Two hundred eighty-six patients (45%) received alvimopan. Alvimopan and no-alvimopan groups had similar demographics, comorbidities, operative indication, and case mix. In the alvimopan group, more of the colorectal resections were laparoscopic (87% vs 79%, p = 0.015). Length of stay was reduced with alvimopan (6.2 vs 4.9 days, p = 0.003), and this effect persisted when controlling for procedure type, approach, and ASA class (decreased length of stay by 1.0 day, p = 0.014). The alvimopan group had lower risk of prolonged length of stay (14.7% vs 23.1%, p = 0.007) and ileus (10.8% vs 16.2%, p = 0.05). On multivariable analysis, no alvimopan use (OR, 1.8; 95% CI, 1.2-2.7), ASA ≥3 (OR, 2.0; 95% CI, 1.3-3.1), and history of cardiac surgery (OR, 2.8; 95% CI, 1.2-6.5) were significant predictors of prolonged length of stay. Alvimopan use was associated with a lower risk of infectious complications other than surgical site infection (2.8% vs 6.7%, p = 0.025), and did not increase risk of any adverse outcomes. The addition of alvimopan to the protocol resulted in cost savings of $708.39 per patient. LIMITATIONS Data collected from a single center limit external validity. CONCLUSIONS The introduction of alvimopan to a postoperative protocol following elective colorectal resection or ostomy reversal significantly reduces length of stay and is associated with cost savings even within an enhanced recovery protocol. See Video Abstract at http://links.lww.com/DCR/A911.
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19
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Prolonged Postoperative Ileus Significantly Increases the Cost of Inpatient Stay for Patients Undergoing Elective Colorectal Surgery: Results of a Multivariate Analysis of Prospective Data at a Single Institution. Dis Colon Rectum 2019; 62:631-637. [PMID: 30543534 DOI: 10.1097/dcr.0000000000001301] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Prolonged postoperative ileus is a common major complication after abdominal surgery. Retrospective data suggest that ileus doubles the cost of inpatient stay. However, current economic impact data are based on retrospective studies that rely on clinical coding to diagnose ileus. OBJECTIVE The aim of this study was to determine the economic burden of ileus for patients undergoing elective colorectal surgery. DESIGN Economic data were audited from a prospective database of patients who underwent surgery at Auckland City Hospital between September 2012 and June 2014. SETTINGS Auckland City Hospital is a large tertiary referral center, using an enhanced recovery after surgery protocol. PATIENTS Patients were prospectively diagnosed with prolonged postoperative ileus using a standardized definition. MAIN OUTCOME MEASURES The cost of inpatient stay was analyzed with regard to patient demographics and operative and postoperative factors. A multivariate analysis was performed to determine the cost of ileus when accounting for other significant covariates. RESULTS Economic data were attained from 325 patients, and 88 patients (27%) developed ileus. The median inpatient cost (New Zealand dollars) for patients with prolonged ileus, including complication rates and length of stay, was $27,981 (interquartile range= $20,198 to $42,174) compared with $16,317 (interquartile range = $10,620 to $23,722) for other patients, a 71% increase in cost (p < 0.005). Ileus increased all associated healthcare costs, including medical/nursing care, radiology, medication, laboratory costs, and allied health (p < 0.05). Multivariate analysis showed that ileus remained a significant financial burden (p < 0.005) when considering rates of major complications and length of stay. LIMITATIONS This is a single-institution study, which may impact the generalizability of our results. CONCLUSIONS Prolonged ileus causes a substantial financial burden on the healthcare system, in addition to greater complication rates and length of stay in these patients. This is the first study to assess the financial impact of prolonged ileus, diagnosed prospectively using a standardized definition. See Video Abstract at http://links.lww.com/DCR/A825.
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Abstract
Postoperative ileus (POI) is a common complication following colon and rectal surgery, with reported incidence ranging from 10 to 30%. It can lead to increased morbidity, cost, and length of stay. Although definitions vary considerably in the literature, in its pathologic form, it can be characterized by a temporary inhibition of gastrointestinal motility after surgical intervention due to nonmechanical causes that prevents sufficient oral intake. Various risk factors for development of POI have been identified including increasing age, American Society of Anesthesiologists scores 3 to 4, open approach, operative difficulty, operative duration more than 3 hours, bowel handling, drop in hematocrit or need for a transfusion, increasing crystalloid administration, and delayed mobilization. While treatment is expectant and supportive, significant investigations into strategies to mitigate development of POI or shorten its duration have been undertaken with mixed results. There is significant evidence to suggest that a minimally invasive approach and multimodal pain regimens reduce the development of POI. The beneficial effect of chewing gum, alvimopan, and enhanced recovery after surgery protocols may decrease development of POI in selected groups of patients who undergo elective colorectal surgery, and shorten time to return of bowel function, but overall, the data remain inconclusive.
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Affiliation(s)
- Cristina R Harnsberger
- Division of Colon and Rectal Surgery, University of Massachusetts, Boston, Massachusetts
| | - Justin A Maykel
- Division of Colon and Rectal Surgery, University of Massachusetts, Boston, Massachusetts
| | - Karim Alavi
- Division of Colon and Rectal Surgery, University of Massachusetts, Boston, Massachusetts
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21
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Affiliation(s)
- Anthony L Kovac
- Department of Anesthesiology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mail Stop 1034, Kansas City, KS 66160, USA.
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22
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Al-Mazrou AM, Baser O, Kiran RP. Alvimopan, Regardless of Ileus Risk, Significantly Impacts Ileus, Length of Stay, and Readmission After Intestinal Surgery. J Gastrointest Surg 2018; 22:2104-2116. [PMID: 29987738 DOI: 10.1007/s11605-018-3846-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 06/13/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous analyses evaluating alvimopan included patients at varying risk for ileus after intestinal resection, which may have precluded its widespread adoption. We assess the early and delayed effects of alvimopan in patients stratified by risk for ileus after intestinal and colon resection. METHODS From the Premier Perspective database, patients with elective small and large bowel resections from 2012 to 2014 were identified. Multivariable analysis identified 14 perioperative risk factors for postoperative ileus. Within low- (0-4 factors), intermediate- (5 factors), and high-risk (6-12 factors) ileus categories, alvimopan and no-alvimopan patients were propensity-score matched for demographics, morbidities, diagnosis, surgery and approach, postoperative complications, surgeon specialty, and hospital features. In-hospital postoperative ileus, length of stay, discharge destination, and ileus-related readmission were compared. RESULTS Of 52,948 patients, 15,719 (29.7%) received alvimopan. Risk for ileus in low- (18,784), intermediate- (14,370), and high-risk (19,794) categories was 8.9, 13, and 22% (p ≤ .0001) respectively. After matching, alvimopan was associated with significantly reduced in-hospital postoperative ileus in all (low, 6%; intermediate, 9.4%; and high risk, 16.2%) categories. Hospital stay and 30-, 60-, and 90-day postdischarge ileus were also significantly lower with alvimopan. For low-risk patients, alvimopan increased discharge to home, while 90-day emergency readmission was reduced. CONCLUSIONS Alvimopan, regardless of ileus risk, improves ileus, hospital stay, and ileus-related readmission after intestinal resection and these effects are sustained over the long term. Since fewer than a third of patients currently receive alvimopan, its routine adoption with small and large intestinal resection will significantly impact patients and health systems.
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Affiliation(s)
- Ahmed M Al-Mazrou
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA
| | - Onur Baser
- Center for Innovation and Outcomes Research, Department of Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Ravi P Kiran
- Division of Colorectal Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, Herbert Irving Pavilion, 161 Fort Washington Avenue, Floor 8, New York, NY, 10032, USA.
- Center for Innovation and Outcomes Research, Department of Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA.
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23
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Alvimopan usage increasing following radical cystectomy. World J Urol 2018; 37:1151-1155. [DOI: 10.1007/s00345-018-2476-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/03/2018] [Indexed: 02/05/2023] Open
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Milne TGE, Jaung R, O'Grady G, Bissett IP. Nonsteroidal anti-inflammatory drugs reduce the time to recovery of gut function after elective colorectal surgery: a systematic review and meta-analysis. Colorectal Dis 2018; 20:O190-O198. [PMID: 29781564 DOI: 10.1111/codi.14268] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Accepted: 04/30/2018] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- T G E Milne
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - R Jaung
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - G O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Colorectal Unit, Department of Surgery, Auckland District Health Board, Auckland, New Zealand
| | - I P Bissett
- Department of Surgery, University of Auckland, Auckland, New Zealand.,Colorectal Unit, Department of Surgery, Auckland District Health Board, Auckland, New Zealand
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Hedrick TL, McEvoy MD, Mythen M(MG, Bergamaschi R, Gupta R, Holubar SD, Senagore AJ, Gan TJ, Shaw AD, Thacker JKM, Miller TE, Wischmeyer PE, Carli F, Evans DC, Guilbert S, Kozar R, Pryor A, Thiele RH, Everett S, Grocott M, Abola RE, Bennett-Guerrero E, Kent ML, Feldman LS, Fiore JF. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Gastrointestinal Dysfunction Within an Enhanced Recovery Pathway for Elective Colorectal Surgery. Anesth Analg 2018; 126:1896-1907. [DOI: 10.1213/ane.0000000000002742] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Slieker J, Hübner M, Addor V, Duvoisin C, Demartines N, Hahnloser D. Application of an enhanced recovery pathway for ileostomy closure: a case–control trial with surprising results. Tech Coloproctol 2018; 22:295-300. [DOI: 10.1007/s10151-018-1778-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 02/05/2018] [Indexed: 12/18/2022]
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Horres CR, Adam MA, Sun Z, Thacker JK, Moon RE, Miller TE, Grant SA. Enhanced recovery protocols for colorectal surgery and postoperative renal function: a retrospective review. Perioper Med (Lond) 2017; 6:13. [PMID: 28948012 PMCID: PMC5609048 DOI: 10.1186/s13741-017-0069-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 09/05/2017] [Indexed: 12/20/2022] Open
Abstract
Background While enhanced recovery protocols (ERPs) reduce physiologic stress and improve outcomes in general, their effects on postoperative renal function have not been directly studied. Methods Patients undergoing major colorectal surgery under ERP (February 2010 to March 2013) were compared with a traditional care control group (October 2004 October 2007) at a single institution. Multivariable regression models examined the association of ERP with postoperative creatinine changes and incidence of postoperative acute kidney dysfunction (based on the Risk, Injury, Failure, Loss, and End-stage renal disease criteria). Results Included were 1054 patients: 590 patients underwent surgery with ERP and 464 patients without ERP. Patient demographics were not significantly different. Higher rates of neoplastic and inflammatory bowel disease surgical indications were found in the ERP group (81 vs. 74%, p = 0.045). Patients in the ERP group had more comorbidities (ASA ≥ 3) (62 vs. 40%, p < 0.001). In unadjusted analysis, postoperative creatinine increase was slightly higher in the ERP group compared with control (median 0.1 vs. 0 mg/dL, p < 0.001), but levels of postoperative acute kidney injury were similar in both groups (p = 0.998). After adjustment with multivariable regression, postoperative changes in creatinine were similar in ERP vs. control (p = 0.25). Conclusions ERP in colorectal surgery is not associated with a clinically significant increase in postoperative creatinine or incidence of postoperative kidney injury. Our results support the safety of ERPs in colorectal surgery and may promote expanding implementation of these protocols. Trial registration Not applicable, prospective data collection and retrospective chart review only.
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Affiliation(s)
- Charles R Horres
- Department of Anesthesiology, Duke University, DUMC 3094, Durham, NC 27710 USA
| | | | - Zhifei Sun
- Department of Surgery, Duke University, Durham, USA
| | | | - Richard E Moon
- Department of Anesthesiology, Duke University, DUMC 3094, Durham, NC 27710 USA
| | - Timothy E Miller
- Department of Anesthesiology, Duke University, DUMC 3094, Durham, NC 27710 USA
| | - Stuart A Grant
- Department of Anesthesiology, Duke University, DUMC 3094, Durham, NC 27710 USA
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Carmichael JC, Keller DS, Baldini G, Bordeianou L, Weiss E, Lee L, Boutros M, McClane J, Steele SR, Feldman LS. Clinical practice guideline for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons (ASCRS) and Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Surg Endosc 2017; 31:3412-3436. [DOI: 10.1007/s00464-017-5722-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 07/10/2017] [Indexed: 12/16/2022]
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29
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Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2017; 60:761-784. [PMID: 28682962 DOI: 10.1097/dcr.0000000000000883] [Citation(s) in RCA: 267] [Impact Index Per Article: 38.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Grass F, Slieker J, Jurt J, Kummer A, Solà J, Hahnloser D, Demartines N, Hübner M. Postoperative ileus in an enhanced recovery pathway-a retrospective cohort study. Int J Colorectal Dis 2017; 32:675-681. [PMID: 28285365 DOI: 10.1007/s00384-017-2789-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2017] [Indexed: 02/04/2023]
Abstract
PURPOSE Enhanced recovery after surgery (ERAS) protocols advocate no nasogastric tubes after colorectal surgery, but postoperative ileus (POI) remains a challenging clinical reality. The aim of this study was to assess incidence and risk factors of POI. METHODS This retrospective analysis included all consecutive colorectal surgical procedures since May 2011 until November 2014. Uni- and multivariate risk factors for POI were identified by multiple logistic regression and functional and surgical outcomes assessed. RESULTS The study cohort consisted of 513 consecutive colorectal ERAS patients. One hundred twenty-eight patients (24.7%) needed postoperative reinsertion of nasogastric tube at the 3.9 ± 2.9 postoperative day. Multivariate analysis retained the American Society of Anesthesiologists group 3-4 (odds ratio (OR) 1.3; 95% CI 1-1.8, p = 0.043) and duration of surgery of >3 h (OR 1.3; 95% CI 1-1.7, p = 0.047) as independent risk factors for POI. Minimally invasive surgery (OR 0.6; 95% CI 0.5-0.8, p ≤ 0.001) and overall compliance of >70% to the ERAS protocol (OR 0.7; 95% CI 0.6-1, p = 0.031) represented independent protective factors. POI was associated with respiratory (23 vs. 5%, p ≤ 0.001) and cardiovascular (16 vs. 3%, p ≤ 0.001) complications. CONCLUSIONS POI was frequent in the present study. Overall compliance to the ERAS protocol and minimally invasive surgery helped to prevent POI, which was significantly correlated with medical complications.
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Affiliation(s)
- Fabian Grass
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Bugnon 46, 1011, Lausanne, Switzerland
| | - Juliette Slieker
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Bugnon 46, 1011, Lausanne, Switzerland
| | - Jonas Jurt
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Bugnon 46, 1011, Lausanne, Switzerland
| | - Anne Kummer
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Bugnon 46, 1011, Lausanne, Switzerland
| | - Josep Solà
- Centre Suisse d'Electronique et de Microtechnique (CSEM), Neuchâtel, Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Bugnon 46, 1011, Lausanne, Switzerland.
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Bugnon 46, 1011, Lausanne, Switzerland
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Alverdy JC, Hyoju SK, Weigerinck M, Gilbert JA. The gut microbiome and the mechanism of surgical infection. Br J Surg 2017; 104:e14-e23. [PMID: 28121030 DOI: 10.1002/bjs.10405] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 09/20/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Since the very early days of surgical practice, surgeons have recognized the importance of considering that intestinal microbes might have a profound influence on recovery from surgical diseases such as appendicitis and peritonitis. Although the pathogenesis of surgical diseases such as cholelithiasis, diverticulosis, peptic ulcer disease and cancer have been viewed as disorders of host biology, they are emerging as diseases highly influenced by their surrounding microbiota. METHODS This is a review of evolving concepts in microbiome sciences across a variety of surgical diseases and disorders, with a focus on disease aetiology and treatment options. RESULTS The discovery that peptic ulcer disease and, in some instances, gastric cancer can now be considered as infectious diseases means that to advance surgical practice humans need to be viewed as superorganisms, consisting of both host and microbial genes. Applying this line of reasoning to the ever-ageing population of patients demands a more complete understanding of the effects of modern-day stressors on both the host metabolome and microbiome. CONCLUSION Despite major advances in perioperative care, surgeons today are witnessing rising infection-related complications following elective surgery. Many of these infections are caused by resistant and virulent micro-organisms that have emerged as a result of human progress, including global travel, antibiotic exposure, crowded urban conditions, and the application of invasive and prolonged medical and surgical treatment. A more complete understanding of the role of the microbiome in surgical disease is warranted to inform the path forward for prevention.
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Affiliation(s)
- J C Alverdy
- Department of Surgery and Laboratory of Surgical Infection Research and Therapeutics, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - S K Hyoju
- Department of Surgery and Laboratory of Surgical Infection Research and Therapeutics, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - M Weigerinck
- Department of Surgery, Radboud University, Nijmegen, The Netherlands
| | - J A Gilbert
- Department of Surgery and Laboratory of Surgical Infection Research and Therapeutics, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
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32
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Ehlers AP, Simianu VV, Bastawrous AL, Billingham RP, Davidson GH, Fichera A, Florence MG, Menon R, Thirlby RC, Flum DR, Farjah F. Alvimopan Use, Outcomes, and Costs: A Report from the Surgical Care and Outcomes Assessment Program Comparative Effectiveness Research Translation Network Collaborative. J Am Coll Surg 2016; 222:870-7. [PMID: 27113517 DOI: 10.1016/j.jamcollsurg.2016.01.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/22/2016] [Accepted: 01/22/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Randomized trials have found that alvimopan hastens return of bowel function and reduces length of stay (LOS) by 1 day among patients undergoing colorectal surgery. However, its effectiveness in routine clinical practice and its impact on hospital costs remain uncertain. STUDY DESIGN We performed a retrospective cohort study of patients undergoing elective colorectal surgery in Washington state (2009 to 2013) using data from a clinical registry (Surgical Care and Outcomes Assessment Program) linked to a statewide hospital discharge database (Comprehensive Hospital Abstract Reporting System). We used generalized estimating equations to evaluate the relationship between alvimopan and outcomes, and adjusted for patient, operative, and management characteristics. Hospital charges were converted to costs using hospital-specific charge to cost ratios, and were adjusted for inflation to 2013 US dollars. RESULTS Among 14,781 patients undergoing elective colorectal surgery at 51 hospitals, 1,615 (11%) received alvimopan. Patients who received alvimopan had a LOS that was 1.8 days shorter (p < 0.01) and costs that were $2,017 lower (p < 0.01) compared with those who did not receive alvimopan. After adjustment, LOS was 0.9 days shorter (p < 0.01), and hospital costs were $636 lower (p = 0.02) among those receiving alvimopan compared with those who did not. CONCLUSIONS When used in routine clinical practice, alvimopan was associated with a shorter LOS and limited but significant hospital cost savings. Both efficacy and effectiveness data support the use of alvimopan in routine clinical practice, and its use could be measured as a marker of higher quality care.
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Affiliation(s)
| | - Anne P Ehlers
- Department of Surgery, University of Washington, Seattle, WA.
| | - Vlad V Simianu
- Department of Surgery, University of Washington, Seattle, WA
| | | | | | | | | | | | - Raman Menon
- Department of Surgery, Swedish Medical Center, Seattle, WA
| | | | - David R Flum
- Department of Surgery, University of Washington, Seattle, WA
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle, WA
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