The Effect of an Enhanced Recovery Program on Elective Right Hemicolectomies for Crohn's Disease vs. Colon Cancer: A Retrospective Cohort Analysis

Pain, opioid consumption, and epidural anesthesia in patients with inflammatory bowel disease undergoing laparoscopic subtotal colectomy: an observational cohort study

BACKGROUND

Surgery is often needed to provide disease control in patients with inflammatory bowel disease. Studies document increased postoperative pain and complicated perioperative courses. This study examines postoperative pain and opioid consumption in patients with inflammatory bowel disease undergoing laparoscopic subtotal colectomy. Furthermore, the impact of epidural anesthesia is investigated.

METHODS

This study encompassed an observational cohort of patients with inflammatory bowel disease undergoing subtotal colectomy in the period 1 January 2018 to 30 June 2023 at a university hospital in Denmark. Demographic and perioperative data, opioid consumption, pain scores, and procedural data of epidural anesthesia were retrieved from patient records. Data were stratified according to the use of epidural anesthesia.

RESULTS

The study included 153 patients. Overall, 45% of patients received epidural anesthesia. Opioid consumption in the postoperative care unit was 9.2 mg (3.3-15.8 mg) and 3.8 mg (0-15 mg) (P = 0.04) in patients without and with epidural anesthesia, respectively. Correspondingly, opioid consumption during the first 24 h postoperatively was 23.3 mg (10-33 mg) and 6.8 mg (0-21.7 mg) (P < 0.001). Numerical rating scale (NRS) pain in the postoperative care unit was 3.5 (2-4.6) and 2.7 (1.3-4.3) in patients without and with epidural anesthesia, respectively (P = 0.1645). Thirty percent of patients treated with epidural anesthesia experienced ≥ 1 adverse event(s) related to epidural anesthesia.

CONCLUSIONS

Our study demonstrates a relatively low consumption of opioids and low pain scores in the early postoperative period following laparoscopic subtotal colectomy regardless of the use of epidural anesthesia. Epidural anesthesia was associated with a substantial frequency of adverse events.

Evidence-based control of stress response on intraoperative physiological indexes and recovery of patients undergoing gastrointestinal surgery

BACKGROUND

Although the 2021 Chinese Clinical Practice Guidelines for Enhanced Recovery after Surgery (ERAS) provide recommendations for ERAS in gastrointestinal surgery, the clinical application of standard ERAS nursing models is challenging due to the variety of diseases involved in gastrointestinal surgery and the complex factors contributing to patient stress responses. Moreover, stress responses are more severe in older adult patients. Therefore, precision medicine is required to improve the quality of nursing care and promote postoperative recovery in gastrointestinal surgery.

AIM

To establish an evidence-based ERAS model based on stress response nursing care and demonstrate nursing benefits through clinical practice.

METHODS

This randomized clinical trial first established an evidence-based nursing ERAS protocol in older adult patients based on literature related to perioperative nursing measures for gastrointestinal surgery stress response. Next, 392 older adult patients who underwent gastrointestinal surgery and were admitted to our hospital between December 2021 and June 2023 were categorized into two groups to receive evidence-based (study group) or conventional (control group) ERAS nursing models, respectively. Intraoperative physiological parameters during surgery and postoperative recovery indicators were compared between the groups.

RESULTS

Among 64 domestic and international studies, the stress responses of older adult patients mainly included emotional anxiety, sleep disorders, gastrointestinal discomfort, physical weakness, pain, and swelling. The appropriate nursing interventions included comprehensive psychological counseling, pre- and postoperative nutritional support, temperature control, pain management, and rehabilitation training. Compared with the control group, the study group showed lower heart rate, mean arterial pressure, blood glucose level, and adrenaline level; shorter duration of drainage tube placement, time to first flatus, time to first ambulation, and postoperative hospital stay; lower anxiety scores on postoperative day 3; and lower incidences of postoperative infection, obstruction, poor wound healing, and gastrointestinal reactions were lower in the study group (all P < 0.05).

CONCLUSION

The evidence-based nursing measures targeting stress responses based on the conventional ERAS nursing model resulted in stable intraoperative physiological parameters during surgery, promoted postoperative recovery, and reduced the incidence of complications.

The implementation of an inflammatory bowel disease-specific enhanced recovery after surgery protocol: an observational cohort study

BACKGROUND

The implementation of Enhanced Recovery After Surgery (ERAS) protocols has resulted in improved postoperative outcomes in colorectal cancer surgery. The evidence regarding feasibility and impact on outcomes in surgery for inflammatory bowel disease (IBD) is limited.

METHODS

We performed a retrospective observational cohort study, comparing patient trajectories before and after implementing an IBD-specific ERAS protocol at Zealand University Hospital. We assessed the occurrence of serious postoperative complications of Clavien-Dindo grade 3 or higher as our primary outcome, with postoperative length of stay in days and rate of readmissions as secondary outcomes, using χ2, Mann-Whitney test, and odds ratios adjusted for sex and age.

RESULTS

From 2017 to 2023, 394 patients were operated on for IBD and included in our study. In the ERAS cohort, 39/250 patients experienced a postoperative complication of Clavien-Dindo grade 3 or higher compared to 27/144 patients in the non-ERAS cohort (15.6% vs. 18.8%, p = 0.420) with an adjusted odds ratio of 0.73 (95% CI 0.42-1.28). There was a significantly shorter postoperative length of stay (median 4 vs. 6 days, p < 0.001) in the ERAS cohort compared to the non-ERAS cohort. Readmission rates remained similar (22.4% vs. 16.0%, p = 0.125).

CONCLUSIONS

ERAS in IBD surgery was associated with faster patient recovery, but without an impact on the occurrence of serious postoperative complications and rate of readmissions.

Risk factors for upper and lower type prolonged postoperative ileus following surgery for Crohn's disease

PURPOSE

Prolonged postoperative ileus (PPOI) is common after bowel resections, especially in Crohn's disease (CD). The pathophysiology of PPOI is not fully understood. PPOI could affect only the upper or lower gastrointestinal (GI) tract. The aim of this study was to assess risk factors for diverse types of PPOI, particularly to differentiate PPOI of upper and lower GI tract.

METHODS

A retrospective analysis of 163 patients with CD undergoing ileocecal resection from 2015 to 2020 in a single center was performed. PPOI of the upper GI tract was predefined as the presence of vomiting or use of nasogastric tube longer than the third postoperative day. Lower PPOI was predefined as the absence of defecation for more than three days. Independent risk factors were identified by multivariable logistic regression analysis.

RESULTS

Overall incidence of PPOI was 42.7%. PPOI of the upper GI tract was observed in 30.7% and lower PPOI in 20.9% of patients. Independent risk factors for upper PPOI included older age, surgery by a resident surgeon, hand-sewn anastomosis, prolonged opioid analgesia, and reoperation, while for lower PPOI included BMI ≤ 25 kg/m², preoperative anemia, and absence of ileostomy.

CONCLUSION

This study identified different risk factors for upper and lower PPOI after ileocecal resection in patients with CD. A differentiated upper/lower type approach should be considered in future research and clinical practice. High-risk patients for each type of PPOI should be closely monitored, and modifiable risk factors, such as preoperative anemia and opioids, should be avoided if possible.