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Khoury MK, Anjorin AC, Demsas F, Mulaney B, Bellomo TR, Dua A, Mohapatra A, Mohebali J, Srivastava SD, Eagleton MJ, Zacharias N. Identifying risk factors for postoperative ileus following open abdominal aortic aneurysm repair. J Vasc Surg 2024:S0741-5214(24)01665-3. [PMID: 39096979 DOI: 10.1016/j.jvs.2024.07.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/05/2024]
Abstract
INTRODUCTION Postoperative ileus (POI) is a common complication following major abdominal surgery. The majority of the data available regarding POI following abdominal surgery is from the gastrointestinal and urologic literature. These data have been extrapolated to vascular surgery, especially with regards to enhanced recovery programs for open abdominal aortic aneurysm (AAA) surgery. However, vascular patients are a unique patient population and extrapolation of gastrointestinal and urological data may not necessarily be appropriate. Therefore, the purpose of this study was to delineate the prevalence and risk factors of POI in patients undergoing open AAA surgery. METHODS This was a retrospective, single-institution study of patients who underwent open AAA surgery from January 2016 to July 2023. Patients were excluded if they had undergone non-elective repairs or had expired within 72 hours of their index operation. The primary outcome was rates of POI, which was defined as the presence of two or more of the following after the third postoperative day: nausea and/or vomiting, inability to tolerate oral food intake, absence of flatus, abdominal distension, or radiological evidence of ileus. RESULTS A total of 123 patients met study criteria with an overall POI rate of 8.9% (n=11). Patients who developed a POI had significantly lower BMIs (24.3 kg/m2 versus 27.1 kg/m2, P=.003), were more likely to undergo a transperitoneal approach (81.8% versus 42.0%, P=.022), midline laparotomy (81.8% versus 37.5%, P=.008), longer total clamp times (151.6 minutes versus 97.7 minutes, P=.018), larger amounts of intraoperative crystalloid infusion (3495 mL versus 2628 mL, P=.029), and were more likely to return to the operating room (27.3% versus 3.6%, P=.016). Proximal clamp site was not associated with POI (P=.463). POI patients also had higher rates of post-operative vasopressor use (100% versus 61.1%, P=.014) and larger amounts of oral morphine equivalents in the first 3 post-operative days (488.0 mg + 216.0 versus 203.8 mg + 29.6 P=.016). Patients who developed POI had longer lengths of stay (12.5 days versus 7.6 days, P<.001), longer duration of NGT decompression (5.9 days versus 2.2 days, P<.001), and a longer period of time before diet tolerance (9.1 days versus 3.7 days, P<.001). Of those that developed a POI (n=11), 4 (36.4%) required total parental nutrition during the admission. CONCLUSION POI is a morbid complication amongst patients undergoing elective open AAA surgery that significantly prolongs hospital stay. Patients at risk for developing a POI are those with lower BMIs, had an operative repair via a transperitoneal approach, midline laparotomy, longer clamp times, larger amounts of intraoperative crystalloid infusion, a return to the operating room, post-operative vasopressor use, and higher amounts of oral morphine equivalents. These data highlight important peri-operative opportunities to reduce the prevalence of POI.
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Affiliation(s)
- Mitri K Khoury
- Massachusetts General Hospital; Division of Vascular and Endovascular Surgery; Boston, MA; HonorHealth Heart Care; Scottsdale, AZ.
| | - Aderike C Anjorin
- Massachusetts General Hospital; Division of Vascular and Endovascular Surgery; Boston, MA
| | - Falen Demsas
- Massachusetts General Hospital; Division of Vascular and Endovascular Surgery; Boston, MA
| | - Bianca Mulaney
- Massachusetts General Hospital; Division of Vascular and Endovascular Surgery; Boston, MA
| | - Tiffany R Bellomo
- Massachusetts General Hospital; Division of Vascular and Endovascular Surgery; Boston, MA
| | - Anahita Dua
- Massachusetts General Hospital; Division of Vascular and Endovascular Surgery; Boston, MA
| | - Abhikesh Mohapatra
- Massachusetts General Hospital; Division of Vascular and Endovascular Surgery; Boston, MA
| | - Jahan Mohebali
- Massachusetts General Hospital; Division of Vascular and Endovascular Surgery; Boston, MA
| | - Sunita D Srivastava
- Massachusetts General Hospital; Division of Vascular and Endovascular Surgery; Boston, MA
| | - Matthew J Eagleton
- Massachusetts General Hospital; Division of Vascular and Endovascular Surgery; Boston, MA
| | - Nikolaos Zacharias
- Massachusetts General Hospital; Division of Vascular and Endovascular Surgery; Boston, MA
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Song J, Zhou C, Zhang T. Prognostic factors associated with gastrointestinal dysfunction after gastrointestinal tumor surgery: A meta-analysis. World J Gastrointest Surg 2024; 16:1420-1429. [PMID: 38817302 PMCID: PMC11135316 DOI: 10.4240/wjgs.v16.i5.1420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/05/2024] [Accepted: 04/15/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND Explore the risk factors of gastrointestinal dysfunction after gastrointestinal tumor surgery and to provide evidence for the prevention and intervention of gastrointestinal dysfunction in patients with gastrointestinal tumor surgery. AIM To investigate the potential risk factors for gastrointestinal dysfunction following gastrointestinal tumor surgery and to present information supporting the prevention and management of gastrointestinal dysfunction in surgery patients. METHODS Systematically searched the relevant literature from PubMed, Web of Science, Cochrane Library, Embase, CNKI, China Biomedical Database, Wanfang Database, and Weipu Chinese Journal Database self-established until October 1, 2022. Review Manager 5.3 software was used for meta-analysis after two researchers independently screened literature, extracted data, and evaluated the risk of bias in the included studies. RESULTS A total of 23 pieces of literature were included, the quality of which was medium or above, and the total sample size was 43878. The results of meta-analysis showed that the patients were male (OR = 1.58, 95%CI: 1.25-2.01, P = 0.002) and ≥ 60 years old (OR = 2.60, 95%CI: 1.76-2.87, P < 0.001), physical index ≥ 25.3 kg/m2 (OR = 1.6, 95%CI: 1.00-1. 12, P = 0.040), smoking history (OR = 1.89, 95%CI: 1.31-2.73, P < 0.001), chronic obstructive pulmonary disease (OR = 1.49, 95%CI: 1.22-1.83, P < 0.001), enterostomy (OR = 1.47, 95%CI: 1.26-1.70, P < 0.001), history of abdominal surgery (OR = 2.90, 95%CI: 1.67-5.03, P < 0.001), surgical site (OR = 1.2, 95%CI: 1.40-2.62, P < 0.001), operation method (OR = 1.68, 95%CI: 1.08-2.62, P = 0.020), operation duration (OR = 2.65, 95%CI: 1.92-3.67, P < 0.001), abdominal adhesion grade (OR = 2.52, 95%CI: 1.90-3.56, P < 0.001), postoperative opioid history (OR = 5.35, 95%CI: 3.29-8.71, P < 0.001), tumor TNM staging (OR = 2.58, 95%CI: 1.84-3.62, P < 0.001), postoperative blood transfusion (OR = 2.92, 95%CI: 0.88-9.73, P = 0.010) is a risk factor for postoperative gastrointestinal dysfunction in patients with gastrointestinal tumors. CONCLUSION There are many factors affecting gastrointestinal dysfunction in gastrointestinal patients after surgery. Clinical staff should identify relevant risk factors early and implement targeted intervention measures on the basis of personalized assessment to improve the clinical prognosis of patients.
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Affiliation(s)
- Jia Song
- Department of Operating Room, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing 210031, Jiangsu Province, China
| | - Cong Zhou
- Department of Gastrointestinal Surgery, Tongji Hospital of Huazhong University of Science and Technology, Wuhan 430073, Hubei Province, China
| | - Tian Zhang
- Department of Disinfection Supply Center, The Fourth Affiliated Hospital of Nanjing Medical University, Nanjing 210031, Jiangsu Province, China
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Tian W, Xu X, Zhao R, Tian T, Li W, Huang M, Zhao Y, Yao Z. High visceral fat-to-muscle ratio predicated a recurrent fistula after definitive surgery for a small intestinal fistula with diffuse extensive abdominal adhesions: a cohort study. Int J Surg 2023; 109:3490-3496. [PMID: 37598405 PMCID: PMC10651287 DOI: 10.1097/js9.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 07/23/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND In patients diagnosed with sarcopenia, the presence of chronic preoperative inflammation, assessed by the ratio of the visceral fat area (VFA) to the total abdominal muscle area index (TAMAI) (VFA/TAMAI), has been found to adversely affect wound healing. An elevated VFA/TAMAI may contribute to a higher incidence of postoperative recurrent fistulas (RFs) following definitive surgery (DS) for small intestinal fistulas accompanied by diffuse extensive abdominal adhesions. The objective of this study was to evaluate the predictive value of VFA/TAMAI for postoperative RFs. METHODS The study enrolled 183 sarcopenic patients, with a median age of 51 years [interquartile range (IQR): 38-61 years), a median body mass index of 19.6 kg/m 2 (IQR: 18.9-21.0 kg/m 2 ) who underwent DS for small intestinal fistulas between January 2018 and October 2022 were included in the multicenter study. The outcomes assessed were RFs and postoperative length of stay (LOS). VFA/TAMAI was examined as a potential risk factor for each outcome. RESULTS Out of the 183 patients, 20.2% ( n =37) developed RFs. The multivariate regression analysis identified VFA/TAMAI as the sole factor associated with RFs [odds ratio=1.78, 95% confidence interval (CI): 1.09-2.87, P =0.02]. The multivariable Cox regression analysis demonstrated that an elevated VFA/TAMAI was linked to a reduced postoperative LOS (hazard ratio=0.69, 95% CI: 0.59-0.81, P <0.001). CONCLUSION In sarcopenic patients, a high VFA/TAMAI predicated the occurrence of RFs after DS for small intestinal fistulas in the presence of diffuse extensive abdominal adhesions.
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Affiliation(s)
- Weiliang Tian
- Research Institute of General Surgery, Jinling Hospital, Nanjing Medical University
| | - Xin Xu
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu
| | - Risheng Zhao
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu
| | - Tao Tian
- Department of General Surgery, Shanghai 9 Hospital, Shanghai
| | - Wuhan Li
- Department of General Surgery, Anhui Provincial Hospital, Hefei, Anhui, People's Republic of China
| | - Ming Huang
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu
| | - Yunzhao Zhao
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu
| | - Zheng Yao
- Department of General Surgery, Jiangning Hospital, Nanjing, Jiangsu
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Tian W, Yao Z, Xu X, Luo S, Zhao R. Effect of preoperative predigested formula vs. polymeric formula on bowel function recovery after definitive surgery for small intestinal entero-atmospheric fistula in patients with chyme reinfusion. Front Nutr 2022; 9:923191. [DOI: 10.3389/fnut.2022.923191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeThe purpose of this study is to compare the effect of preoperative predigested formula vs. polymeric formula on bowel function recovery following definitive surgery (DS) for small intestinal enteroatmospheric fistula (EAF).MethodsIn this retrospective study, from January 2005 to December 2019, the patients with small intestinal EAF and receiving a DS were enrolled. During the preoperative treatment, each patient received enteral nutrition via nasojejunal feeding and chyme reinfusion. The enrolled subjects were classified into two groups, based on their formula type: polymeric formula and predigested formula. Then, propensity scores matching (PSM) was used to further divide these patients into PSM polymeric formula group or PSM predigested formula group. The clinical characteristics of the groups were analyzed.ResultA total of 137 patients were finally enrolled, with 72 patients in the polymeric formula group and 65 patients in predigested formula group. The postoperative ileus was manifested in a total of 61 (44.5%) cases, with 27 (37.5%) in the polymeric formula group and 34 (52.3%) in the predigested formula group (P = 0.04). It was predicted that the polymeric formula could result in a reduction in postoperative ileus (OR = 0.47; 95% CI: 0.21–0.95; P = 0.04). After 1:1 PSM, there were 110 patients included. The postoperative ileus was observed in 47 patients, with 18 (32.7%) in the polymeric formula group and 29 (52.7%) in the predigested formula group (P = 0.03). After PSM, the polymeric formula demonstrated a reduction in the incidence of postoperative ileus (OR = 0.42; 95% CI: 0.19–0.92; P = 0.03).ConclusionCompared with predigested formula, the preoperative polymeric formula appears to be associated with earlier recovery of bowel function after DS for EAF.
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Tian W, Zhao R, Xu X, Zhao Y, Luo S, Tao S, Yao Z. Chyme Reinfusion Reducing the Postoperative Complications After Definitive Surgery for Small Intestinal Enteroatmospheric Fistula: A Cohort Study. Front Nutr 2022; 9:708534. [PMID: 35265651 PMCID: PMC8898887 DOI: 10.3389/fnut.2022.708534] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose This study is aimed to reveal the role of preoperative chyme reinfusion (CR) in reducing the complications occurring after definitive surgery (DS) for small intestinal enteroatmospheric fistula (EAF). Methods In this study, from January 2012 to December 2019, the patients with small intestinal EAF and receiving a definitive surgery were recruited. Depending on whether the CR has been performed, these patients were divided into either the CR group or the non-CR group. Then, propensity scores matching (PSM) was used to further divide these patients into the PSM CR group or the PSM none-CR group. The clinical characteristics exhibited by the groups were analyzed, and the effect of preoperative CR was investigated. Result A total of 159 patients were finally recruited with 72 patients in the CR group and 87 patients in the non-CR group. The postoperative complications were manifested in a total of 126 cases (79.3%). There were 49 cases in the CR group, and 77 cases in the non-CR group. CR was associated with the occurrence of postoperative complications (multivariate odds ratio [OR] = 0.289; 95% CI: 0.123-0.733; p = 0.006). After 1:1 PSM, there were 92 patients included. The postoperative complications were observed in 67 out of these 92 patients. There were 26 patients in the PSM CR group, and 41 patients in the PSM non-CR group. CR was associated with postoperative complications (multivariate OR = 0.161; 95% CI: 0.040-0.591; p = 0.002). In addition, CR played a role in reducing the recurrence of fistula both before (multivariate OR = 0.382; 95% CI: 0.174-0.839; p = 0.017) and after (multivariate OR = 0.223; 95% CI: 0.064-0.983; p = 0.034) PSM. In addition, there is a protective factor at play for those patients with postoperative ileus before (multivariate OR = 0.209; 95% CI: 0.095-0.437; p < 0.001) and after (multivariate OR = 0.222; 95% CI: 0.089-0.524; p < 0.001) PSM. However, the relationship between CR and incision-related complications was not observed in this study. Conclusion Preoperative CR is effective in reducing postoperative complications after definitive surgery was performed for EAF.
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Affiliation(s)
- Weiliang Tian
- Department of General Surgery, Jinling Hospital, Nanjing, China
| | - Risheng Zhao
- Department of General Surgery, Jiangning Hospital, Nanjing, China
| | - Xin Xu
- Department of General Surgery, Jiangning Hospital, Nanjing, China
| | - Yunzhao Zhao
- Department of General Surgery, Jinling Hospital, Nanjing, China.,Department of General Surgery, Jiangning Hospital, Nanjing, China
| | - Shikun Luo
- Department of General Surgery, Jiangning Hospital, Nanjing, China
| | - Shen Tao
- Department of General Surgery, Nanjing 83 Hospital, Nanjing, China
| | - Zheng Yao
- Department of General Surgery, Jiangning Hospital, Nanjing, China
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Huang M, Tian W, Luo S, Xu X, Yao Z, Zhao R, Huang Q. Duration of postoperative hyperlactatemia has predictive value in recurrent fistula after major definitive surgery for intestinal fistula. BMC Surg 2022; 22:14. [PMID: 35033052 PMCID: PMC8761294 DOI: 10.1186/s12893-022-01465-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
Purpose The present study aimed to identify the predictive value of duration of postoperative hyperlactatemia in screening patients at high risk of recurrent fistula after major definitive surgery (DS) for intestinal fistula. Methods If the initial postoperative lactate (IPL) > 2 mmol/L, DS was defined as major definitive surgery. The 315 enrolled patients with major DS were divided into group A (2 mmol/L < IPL ≤ 4 mmol/L), group B (mmol/L < IPL ≤ 6 mmol/L), and group C (IPL > 6 mmol/L). The characteristics of patients were collected, and the duration of postoperative hyperlactatemia was analyzed. According to the occurrence of recurrent fistula (RF), patients were further divided into RF group A, and Non-RF group A; RF group B, and Non-RF group B; and RF group C, and Non-RF group C. Results The duration of postoperative hyperlactatemia was comparable between the RF group A and the Non-RF group A [12 (IQR: 12–24) vs 24 (IQR: 12–24), p = 0.387]. However, the duration of hyperlactatemia was associated with RF in group B (adjusted OR = 1.061; 95% CI: 1.029–1.094; p < 0.001) and group C (adjusted OR = 1.059; 95% CI: 1.012–1.129; p = 0.017). In group B, the cutoff point of duration of 42 h had the optimal predictive value (area under ROC = 0.791, sensitivity = 0.717, specificity = 0.794, p < 0.001). In group C, the cutoff point of duration of 54 h had the optimal predictive value (area under ROC = 0.781, sensitivity = 0.730, specificity = 0.804, p < 0.001). Conclusion The duration of postoperative hyperlactatemia has a value in predicting RF in patients with an IPL of more than 4 mmol/L after major definitive surgery for intestinal fistula.
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Affiliation(s)
- Ming Huang
- Department of General Surgery, Jiangning Hospital, Hushan Road No. 169, Nanjing, Jiangsu, China
| | - Weiliang Tian
- Department of General Surgery, Jinling Hospital, Nanjing, Jiangsu, China
| | - Shikun Luo
- Department of General Surgery, Jiangning Hospital, Hushan Road No. 169, Nanjing, Jiangsu, China.
| | - Xi Xu
- Department of General Surgery, Jiangning Hospital, Hushan Road No. 169, Nanjing, Jiangsu, China
| | - Zheng Yao
- Department of General Surgery, Jiangning Hospital, Hushan Road No. 169, Nanjing, Jiangsu, China.
| | - Risheng Zhao
- Department of General Surgery, Jiangning Hospital, Hushan Road No. 169, Nanjing, Jiangsu, China
| | - Qian Huang
- Department of General Surgery, Jinling Hospital, Nanjing, Jiangsu, China
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Yao Z, Tian W, Xu X, Zhao R, Zhao Y. Compared With a Nasointestinal Route, Pre-operative Enteral Nutrition via a Nasogastric Tube Reduced the Incidence of Acalculous Acute Cholecystitis After Definitive Surgery for Small Intestinal Fistula. Front Med (Lausanne) 2021; 8:721402. [PMID: 34485348 PMCID: PMC8415823 DOI: 10.3389/fmed.2021.721402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 07/27/2021] [Indexed: 11/27/2022] Open
Abstract
Purpose: This study aimed to investigate the difference in the efficacy of pre-operative enteral nutrition (EN) via a nasogastric tube (NGT) and pre-operative EN via a nasointestinal tube (NIT) in reducing the incidence of post-operative acalculous acute cholecystitis (AAC) after definitive surgery (DS) for small intestinal fistulas. Methods: Patients with a small intestinal fistula, who had a DS for the disease between January 2015 and March 2021, were enrolled in this study. They were divided into the NIT group and the NGT group based on the pre-operative routes of feeding they received. The clinical characteristics of the two groups were analyzed, and the incidences of post-operative AAC in the two groups were evaluated. Results: A total of 200 patients were enrolled in the study, 85 in the NGT group and 115 in the NIT group. Thirty-one patients developed post-operative AAC (8 in the NGT group and 23 in the NIT group). The incidence of post-operative AAC was 15.5%. EN via the NGT route was associated with a reduction in the incidence of post-operative AAC (adjusted HR = 0.359; 95% CI: 0.139–0.931; P = 0.035). Conclusion: Pre-operative EN via the NGT may reduce the incidence of post-operative AAC in patients who received a DS for small intestinal fistulas.
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Affiliation(s)
- Zheng Yao
- Department of General Surgery, Jiangning Hospital, Nanjing, China
| | - Weiliang Tian
- Department of General Surgery, Jinling Hospital, Nanjing, China
| | - Xin Xu
- Department of General Surgery, Jiangning Hospital, Nanjing, China
| | - Risheng Zhao
- Department of General Surgery, Jiangning Hospital, Nanjing, China
| | - Yunzhao Zhao
- Department of General Surgery, Jiangning Hospital, Nanjing, China.,Department of General Surgery, Jinling Hospital, Nanjing, China
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