Risk factors for postoperative ileus following orthopedic surgery: the role of chronic constipation

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risk Factors for Postoperative Ileus in Patients Undergoing Spine Surgery

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.

A Common Complication in Orthopedic Patients: Postoperative Constipation and Related Risk Factors

PURPOSE

The purpose of this study was to determine the frequency of postoperative constipation and risk factors in orthopedic patients.

DESIGN

A descriptive model was used.

METHODS

A total of 140 patients who underwent surgical intervention in the Orthopedics and Traumatology Clinic were included in the present study. The Descriptive Characteristics Form, Constipation Risk Assessment Scale, and Visual Analog Scale were used to collect the study data. Frequencies, percentages, Mann Whitney U, Kruskal-Wallis, and Spearman Correlation tests were used to evaluate the data.

FINDINGS

In the present study, 72.1% of the individuals experienced constipation during the hospitalization period, and the constipation risk score was 12.77.á...á4.83. Those who were female, over 65 years old, unemployed, had lower extremity surgery, used opioid analgesics, were dependent on their activities, had prehospital constipation, had a chronic disease, and used drugs regularly had higher constipation risk scores at statistically significant levels. A significant correlation was detected between the constipation risk score and age, pain severity, hospital stay, time to first defecation after surgery, and the amount of fluid consumed daily.

CONCLUSIONS

The majority of the individuals experienced constipation during the hospitalization period, and the constipation risk score was moderate. Those who were female, had advanced age, were unemployed, had high pain severity, opioid use, previous constipation, chronic disease, regular medication, long hospital stay, those whose first defecation period was prolonged after the surgery and whose fluid intake was insufficient had a higher risk of constipation. In this regard, nurses must evaluate orthopedic patients in terms of constipation risk factors and apply nondrug methods that prevent and relieve constipation with laxatives.

A standardized postoperative bowel regimen protocol after spine surgery

Objectives

Spine surgery is associated with early impairment of gastrointestinal motility, with postoperative ileus rates of 5–12%. A standardized postoperative medication regimen aimed at early restoration of bowel function can reduce morbidity and cost, and its study should be prioritized.

Methods

A standardized postoperative bowel medication protocol was implemented for all elective spine surgeries performed by a single neurosurgeon from March 1, 2022 to June 30, 2022 at a metropolitan Veterans Affairs medical center. Daily bowel function was tracked and medications were advanced using the protocol. Clinical, surgical, and length of stay data are reported.

Results

Across 20 consecutive surgeries in 19 patients, mean age was 68.9 years [standard deviation (SD) = 10; range 40–84]. Seventy-four percent reported preoperative constipation. Surgeries consisted of 45% fusion and 55% decompression; lumbar retroperitoneal approaches constituted 30% (10% anterior, 20% lateral). Two patients were discharged in good condition prior to bowel movement after meeting institutional discharge criteria; the other 18 cases all had return of bowel function by postoperative day (POD) 3 (mean = 1.8-days, SD = 0.7). There were no inpatient or 30-day complications. Mean discharge occurred 3.3-days post-surgery (SD = 1.5; range 1–6; home 95%, skilled nursing facility 5%). Estimated cumulative cost of the bowel regimen was $17 on POD 3.

Conclusions

Careful monitoring of return of bowel function after elective spine surgery is important for preventing ileus, reducing healthcare cost, and ensuring quality. Our standardized postoperative bowel regimen was associated with return of bowel function within 3 days and low costs. These findings can be utilized in quality-of-care pathways.

What Are Risk Factors for an Ileus After Posterior Spine Surgery?-A Case Control Study

STUDY DESIGN

Case-Control Study.

OBJECTIVE

The purpose of this retrospective study is to evaluate risk factors for developing a postoperative ileus after posterior spine surgery.

METHODS

Patient charts, including radiographs were evaluated retrospectively. Diagnosis of an ileus was confirmed radiographically by a CT scan in all cases. The control group was retrieved by selecting a random sample of patients undergoing posterior spine surgery who did not develop bowel dysfunction postoperatively.

RESULTS

A total of 40 patients had a postoperative ileus. The control group consisted of 80 patients. Both groups did not differ significantly in age, gender, BMI, tobacco use, comorbidities or status of previous abdominal surgery. Significant differences between the 2 groups was the length of stay (5.9 vs. 11.2; p = 0.001), surgery in the lumbar spine (47.5% vs. 87.5%; p < 0.001) and major spine surgery involving > 3 levels (35.0% vs. 57.5%; p = 0.019). Patients who suffered from an ileus were more likely to be treated in ICU (23.8% vs. 37.5%; p = 0.115), being re-admitted (0.0% vs 5.0%; p = 0.044) and having a delayed discharge (32.5% vs. 57.5%; p = 0.009). Multivariable analysis demonstrated that lumbar spine surgery compared to thoracic and/or cervical spine surgery (p = 0.00, OR 8.7 CI 2.9-25.4) and major spine surgery involving > 3 levels (p = 0.012; OR 3.0, CI 1.3-7.2) are associated with developing an ileus postoperatively.

CONCLUSION

Surgeries of the lumbar spine as well as those involving > 3 levels are associated with developing a postoperative ileus. Further studies are needed to expand on possible risk factors and to better understand the mechanism underlying postoperative ileus in spine surgery patients.

Clinical Importance, Incidence and Risk Factors for the Development of Postoperative Ileus Following Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective observational study of a cohort of consecutive patients.

OBJECTIVES

Postoperative ileus (POI) is associated with a variety of adverse effects. Although the incidence of and risk factors for POI following spinal surgery have been reported, the frequency and pathology of POI after spinal corrective surgery for adult spinal deformity (ASD) are still largely unknown. The study objectives were to: (1) clarify the prevalence and clinical significance of POI, (2) elucidate the risk factors for POI, (3) determine radiographically which preoperative and/or postoperative spinal parameters predominantly influence the risk of POI after spinal corrective surgery for ASD.

METHODS

We included data from 144 consecutive patients who underwent spinal corrective surgery. Perioperative medical complications and clinical information were extracted from patient electronic medical records. Preoperative radiographic parameters and changes in radiographic parameters after surgery were compared between patients with and without POI. Multivariate logistic regression analyses were performed to clarify potential risk factors for POI.

RESULTS

POI developed in 25/144 (17.4%) patients and was the most common complication in the present study. The frequencies of smoking, gastroesophageal reflux disease, and lateral lumbar interbody fusion (LLIF), as well as the duration of surgery were significantly greater in the group with POI versus the group without POI. Among radiographic parameters, only the change in thoracolumbar kyphosis (TLK) from before to after surgery was significantly larger in the group with POI. Multivariate logistic regression analysis showed that male sex, LLIF and large changes in TLK from before to after surgery were significantly associated with the development of POI.

CONCLUSIONS

These results suggested that LLIF and large corrections in TLK were independent risk factors for POI after ASD surgery. When patients with ASD have large TLK preoperatively, and it is determined that a large correction is needed, physicians must be aware of the potential for occurrence of POI.

Aspiration pneumonia and anesthesia techniques in hip fracture surgery in elderly patients: A retrospective cohort study using administrative data

Purpose: Aspiration pneumonia is a critical issue. General anesthesia may suppress the airway's protective reflex. However, aspiration pneumonia is also observed in patients who undergo hip fracture surgery under spinal anesthesia. The aim of this study was to investigate the relationship between anesthesia methods and aspiration pneumonia as well as the predictive factors of aspiration pneumonia in elderly patients undergoing hip fracture surgery. Methods: The medical records of 19,809 patients aged ≥60 years who underwent hip fracture surgery under general or spinal anesthesia were reviewed. After propensity score matching, the anesthesia methods affecting the occurrences of aspiration pneumonia and other complications were investigated via logistic regression and instrumental variable analyses. Predictive factors of aspiration pneumonia were also investigated in all subjects using a multivariable logistic regression analysis. Results: Among the 11,673 general anesthesia patients and 8136 spinal anesthesia patients, aspiration pneumonia occurred in 356 patients (1.8%). Post-propensity score matching the incidences of aspiration pneumonia with general and spinal anesthesia were 1.8% and 1.5%, respectively (p = 0.158); other pulmonary complications were 1.5% and 1.5%, respectively (p = 0.893); and the mortality rates were 1.4% and 1.2%, respectively (p = 0.219). The predictive factors of aspiration pneumonia were advanced age, male sex, lean body, cerebrovascular disease, dementia, and dependency for activities of daily living (eating). Conclusion: Spinal and general anesthesia showed similar incidences of aspiration pneumonia in elderly hip fracture surgery. Regardless of the anesthesia method, great care should be taken, especially in elderly patients with the identified predictive factors.

Enhanced Recovery after Surgery Protocol Accelerates Recovery of Lumbar Disc Herniation among Elderly Patients Undergoing Discectomy via Promoting Gastrointestinal Function

This study aimed to analyze the effect of the enhanced recovery after surgery (ERAS) protocol on the recovery of gastrointestinal function in patients with lumbar disc herniation after discectomy. A total of 179 patients with lumbar disc herniation were randomly divided into the ERAS and non-ERAS groups. The non-ERAS group received routine nursing, and the ERAS group received ERAS strategy. The two groups were compared for general recovery indicators such as postoperative hemoglobin and prealbumin, satisfaction, and length of hospital stay. Gastrointestinal function was also evaluated, such as postoperative feeding time, intestinal chirping recovery time, intestinal exhaust gas recovery time, and complications such as ileus, nausea, and vomiting. The satisfaction of patients in the ERAS group (86.15 ± 2.43) was significantly higher than that in the non-ERAS group (77.19 ± 3.32), and the difference was statistically significant (P < 0.05). The average time of eating in the ERAS group was 2.27 h after surgery. In addition, the amount of eating in the ERAS group was significantly better than that in the non-ERAS group, and the difference was statistically significant. In the ERAS group, intestinal chirping recovery time recovered to normal time, and exhaust recovery time and average defecation time were significantly shorter than those in the non-ERAS group. In the ERAS group, the average amount of hemoglobin and prealbumin decreased 3 days after operation, which was significantly lower than that in the non-ERAS group. To sum up, ERAS has an evident effect on the recovery of gastrointestinal function after discectomy of disc herniation, which can promote the recovery of patients.

Laxative use and mortality in patients on haemodialysis: a prospective cohort study

BACKGROUND

Patients on haemodialysis (HD) are often constipated. This study aimed to assess the relationship between constipation and mortality in such patients. In this study, constipation was defined as receiving prescription laxatives, based on the investigation results of "a need to take laxatives is the most common conception of constipation" reported by the World Gastroenterology Organization Global Guidelines.

METHODS

This cohort study included 12,217 adult patients on HD enrolled in the Japan-Dialysis Outcomes and Practice Patterns study phases 1 to 5 (1998 to 2015). The participants were grouped into two based on whether they were prescribed laxatives during enrolment at baseline. The primary endpoint was all-cause mortality in 3 years, and the secondary endpoint was cause-specific death. Missing values were imputed using multiple imputation methods. All estimations were calculated using a Cox proportional hazards model with an inverse probability of treatment weighting using the propensity score.

RESULTS

Laxatives were prescribed in 30.5% of the patients, and there were 1240 all-cause deaths. There was a significant association between laxative prescription and all-cause mortality [adjusted hazard ratio (AHR), 1.12; 95% confidence interval (CI): 1.03 to 1.21]. Because the Kaplan-Meier curves of the two groups crossed over, we examined 8345 patients observed for more than 1.5 years. Laxative prescription was significantly associated with all-cause mortality (AHR, 1.35; 95% CI: 1.17 to 1.55). The AHR of infectious death was 1.62 (95% CI: 1.14 to 2.29), and that of cancerous death was 1.60 (95% CI: 1.08 to 2.36). However, cardiovascular death did not show a significant inter-group difference.

CONCLUSIONS

Constipation requiring use of laxatives was associated with an increased risk of death in patients on HD. It is important to prevent patients receiving HD from developing constipation and to reduce the number of patients requiring laxatives.

Bowel dysfunction after elective spinal surgery: etiology, diagnostics and management based on the medical literature and experience in a university hospital

BACKGROUND

Bowel dysfunction after spinal surgery is often underestimated and if not treated in a timely manner can lead to undesirable surgical interventions or fatal complications. The current medical literature primarily focuses on bowel dysfunction as a result of spinal injury.

OBJECTIVE

The purpose of this review is to explore this topic in evaluating current evidence regarding the causes of acute bowel dysfunction after elective spinal surgery, primarily the thoracolumbar spine. Since available evidence for recommendations of treatment is scarce, an interdisciplinary management approach for treatment of bowel dysfunction following spinal surgery is also formulated.

MATERIAL AND METHODS

An extensive literature search was carried out on PubMed. Keywords that were used in the search included bowel dysfunction, obstruction, postoperative ileus, spinal surgery, spinal fusion, constipation, opioid-induced constipation, colonic pseudo-obstruction, ischemic colitis, immobility-induced bowel changes, epidural anesthesia and diet. Relevant studies were chosen and included in the review. The treatment approach used in the spine center of a university hospital was included.

RESULTS

Current research mainly focuses on investigating the nature and symptomatology of chronic bowel dysfunction after spinal cord injury. Emphasis on the acute phase of bowel dysfunction in patients after elective spinal surgery is lacking. The comorbidities that exacerbate bowel dysfunction postoperatively are well-defined. There has been refinement and expansion of the pharmacological and nonpharmacological treatment that could be implemented. Enough evidence exists to provide sufficient care.

CONCLUSION

Management of acute bowel dysfunction after spinal surgery requires a comprehensive and individualized approach, encompassing comorbidities, behavioral changes, medications and surgery. Close supervision and timely treatment could minimize further complications. Research is required to identify patients who are at a higher risk of developing bowel dysfunction after specific spinal procedures.

Defecation delay in patients after lung tumor surgery: a prospective nested case-control study

Background

Defecation delay (greater than or equal to 3 days post-surgery) is a common symptom in patients after lung tumor surgery. This study investigated the incidence and relevant risk factors of defecation delay in patients after lung tumor surgery.

Methods

Between October 2019 and March 2020, a prospective nested case-control study was conducted in 80 patients who received lung tumor surgery in the Department of Thoracic Surgery at the Sun Yat-sen University Cancer Center. According to the Rome III criteria for functional constipation and the accepted definitions in the literature, patients with defecation delay time greater than or equal to 3 days post-surgery were classified as the defecation delay group, and the remaining patients were considered the control group. A questionnaire survey was conducted to explore the trait of the stool, defecation time, postoperative activity, diet, and perioperative pain score. Statistical analyses were performed to compare the risk factors affecting defecation time in the two groups.

Results

Out of 80 patients, a total of 44 patients (44/80) experienced defecation delay after the operation. Univariate analysis showed that there were significant differences between the two groups in operation methods (P<0.029), postoperative stool trait (P<0.001), difficulty in defecation (P<0.01), and perioperative pain score (P=0.0178), suggesting that change of stool characteristics and pain were possible factors causing defecation delay. Multivariate analysis also revealed significant differences between the two groups in the postoperative pain score on the first day post-surgery (P=0.03).

Conclusions

Defecation delay is a common symptom in patients after lung cancer surgery, and is related to operation method, pain score, and changes in stool characteristics. This study identified that minimally invasive surgery, postoperative pain relief treatment, and health education may play an important role in preventing delayed defecation.

A prospective randomized controlled trial to evaluate effect of chewing gum on postoperative ileus in elderly patient after hip fracture

Factors related to developing postoperative ileus (POI) vary from pharmacologic, inflammatory, hormonal, metabolic, gastrointestinal physiology, neurologic, to psychological factors. Although orthopedic-related incidence of postoperative ileus is about 10%, these studies are limited to spine surgery and pelvic surgery. The purpose of this study was to investigate prevalence of POI and to analyze effect of chewing gum on POI and bowel function in elderly patients after hip fracture surgery.A prospective randomized controlled trial was conducted at the Gyeongsang National University Hospital. Elderly patients with hip fracture who underwent surgery from March 2017 to June 2018 were eligible to participate. Patients were excluded if they had a mastication disability, impaired cognitive function, previous history of gastrointestinal disease, respiratory disease and low oxygen saturation, hip arthroplasty with causes other than hip fractures, acetabular fractures, periprosthetic fractures, or pathological fractures. Patients with consciousness problem by excessive anesthesia were also excluded. Patients were classified into 2 groups by randomization. Group I received sugar-free gum and were encouraged to chew 6 hours following surgery until the first intestinal gas is released. Group II was given the same postoperative procedure and encouraged to consume water after 6 hours.After applying exclusion criteria, 74 patients were finally included. Thirty-one patients were classified to Group I and 43 patients were classified to the Group II. Prevalence of POI in all patients with hip fracture was 63.5% (47/74). Prevalence of POI in Group I was statistically significant lower than that in Group II (Group I: 41%, Group II: 79.1%, P = .01)The prevalence of POI in elderly patients with hip fracture was 63.5%. Chewing gum had a significant effect on reduction of POI in elderly patients with hip fractures.

Incidence and Risk of Severe Ileus After Orthopedic Surgery: A Case-Control Study

BACKGROUND

Post-operative ileus (POI) is common and can be associated with significant morbidity.

QUESTIONS/PURPOSES

We aimed to identify the incidence of and risk factors associated with severe post-operative ileus (SPOI) after elective orthopedic surgery.

METHODS

We conducted a retrospective case-control study of patients undergoing elective orthopedic procedures at a single musculoskeletal specialty hospital. SPOI cases matched 1:2 to non-POI controls. International Classification of Diseases, Ninth Revision (ICD-9), codes were used to identify patients who were coded as having an episode of POI. After chart review, a subset was classified as clinical SPOI cases, based on set criteria. Regression models were constructed to identify variables associated with SPOI.

RESULTS

Of 273 POI cases, 77 (28.2%) were classified as SPOI. Overall rates of SPOI were 2.74/1000 orthopedic discharges, with SPOI most common in spine surgeries (9.07/1000 spine procedure discharges). Hypothesis-generating multivariable conditional logistic regression suggested that, for hip and knee cases, not being on a full diet by post-operative day (POD) 2 posed an increased risk of SPOI. For spine cases, not being on a full diet on POD 2 and longer surgery times were associated with risk of SPOI.

CONCLUSIONS

In this retrospective case-control study, patients undergoing elective orthopedic procedures who had not progressed to full diet by POD 2 and spine patients with longer operative times were most at risk for SPOI. These data can be used clinically by peri-operative physicians to stratify patients according to risk.

Paralytic ileus in the United States: A cross-sectional study from the national inpatient sample

Introduction:

Paralytic ileus is a common clinical condition leading to significant morbidity and mortality. Most studies to date have focused on postoperative ileus, a common but not exclusive cause of the condition. There are limited epidemiological data regarding the incidence and impact of paralytic ileus and its relationship to other clinical conditions. In this cross-sectional study, we analyzed national inpatient hospitalization trends, demographic variation, cost of care, length of stay, and mortality for paralytic ileus hospitalizations as a whole.

Methods:

The National Inpatient Sample database was used to identify all hospitalizations with the diagnosis of paralytic ileus (International Classification of Diseases, 9th Revision code 560.1) as primary or secondary diagnosis during the period from 2001 to 2011. Statistical analysis was performed using Cochran–Armitage trend test, Wilcoxon rank sum test, and Poisson regression.

Results:

In 2001, there were 362,561 hospitalizations with the diagnosis of paralytic ileus as compared to 470,110 in 2011 (p < 0.0001). The age group 65–79 years was most commonly affected by paralytic ileus throughout the study period. In-hospital all-cause mortality decreased from 6.03% in 2001 to 5.10% in 2011 (p < 0.0001). However, the average cost of care per hospitalization increased from US$19,739 in 2001 to US$26,198 in 2011 (adjusted for inflation, p < 0.0001).

Conclusion:

There was a significant rise in the number of hospitalizations of paralytic ileus with increased cost of care and reduced all-cause mortality.

Comparison Study of Patient Demographics, Risk Factors, and Lengths of Stay for Postoperative Ileus After Primary Total Knee Arthroplasty

BACKGROUND

Postoperative ileus is a potential complication after orthopedic surgery, which has not been well studied after total knee arthroplasty (TKA). The aims of this study were to analyze rates of postoperative ileus; patient demographic profiles; in-hospital lengths of stay (LOS); and patient-related risk factors for postoperative ileus after primary TKA.

METHODS

A query was performed from January 1, 2005 to March 31, 2014 using the Medicare Standard Analytical Files. Patients who underwent primary TKA and developed postoperative ileus within 3 days after their index procedure were identified. Patients who did not develop ileus represented controls. Primary outcomes analyzed and compared included patient demographics, risk factors, and in-hospital LOS. A P value less than .05 was considered statistically significant.

RESULTS

Ileus patients were older, more likely to be male, and had higher Elixhauser-Comorbidity Index scores (8 vs 6; P < .0001) compared with controls. Male patients (odds ratio [OR], 2.12; P < .0001), patients with preoperative electrolyte/fluid imbalance (OR, 3.40; P < .001), patients older than 70 years (OR, 1.62-2.33; P < .015), and body mass indices greater than 30 kg/m² (OR, 1.79-2.00; P < .001) were at the greatest risk of developing ileus. In addition, ileus patients had significantly longer in-hospital LOS (5.42 vs 3.22 days; P < .001).

CONCLUSION

The study demonstrated differences in patient demographics, patient-related risk factors, and an increased in-hospital LOS for ileus patients after primary TKA. The study is important as it can allow orthopedists to properly identify and optimize patients with certain risk factors to potentially mitigate this adverse event from occurring.

Systemic Complications and Radiographic Findings of Opioid Use and Misuse: An Overview for Orthopedic Surgeons

Amid growing concern about the misuse of prescribed opioids, the rising rates of opioid use disorder, and the use of illicit opioids, clinicians in ambulatory, inpatient, and operative environments are encountering opioid-related complications in their patients. These complications can affect multiple organ systems including cardiovascular, pulmonary, gastrointestinal, and neurologic and are related to excess opioid levels in the body or contamination from non-sterile injection. It is important for the orthopedic surgeon to have a general understanding of the pathologies associated with opioid use disorder and their appearance on diagnostic imaging. This article reviews image findings of several complications, organized in a systems-based approach, for the orthopedic surgeon.

Perioperative impact of sleep apnea in a high-volume specialty practice with a strong focus on regional anesthesia: a database analysis

Background and objectives

Obstructive sleep apnea (OSA) is a risk factor for adverse postoperative outcome and perioperative professional societies recommend the use of regional anesthesia to minimize perioperative detriment. We studied the impact of OSA on postoperative complications in a high-volume orthopedic surgery practice, with a strong focus on regional anesthesia.

Methods

After Institutional Review Board approval, 41 766 cases of primary total hip and knee arthroplasties (THAs/TKAs) from 2005 to 2014 were extracted from institutional data of the Hospital for Special Surgery (approximately 5000 THAs and 5000 TKAs annually, of which around 90% under neuraxial anesthesia).

The main effect was OSA (identified by the International Classification of Diseases, ninth revision codes); outcomes of interest were cardiac, pulmonary, gastrointestinal, renal/genitourinary, thromboembolic complications, delirium, and prolonged length of stay (LOS). Multivariable logistic regression models provided ORs, corresponding 95% CIs, and p values.

Results

Overall, OSA was seen in 6.3% (n=1332) of patients with THA and 9.1% (n=1896) of patients with TKA. After adjustment for relevant covariates, OSA was significantly associated with 87% (OR 1.87, 95% CI 1.51 to 2.30), 52% (OR 1.52, 95% CI 1.13 to 2.04), and 44% (OR 1.44,95% CI 1.31 to 1.57) increased odds for pulmonary gastrointestinal complications, and prolonged LOS, respectively. The odds for other outcomes remained unaltered by OSA diagnosis.

Conclusion

We showed that, even in a setting with almost universal regional anesthesia use, OSA was associated with increased odds for prolonged LOS, and pulmonary and gastrointestinal complications. This puts forward the question of how effective regional anesthesia is in mitigating postoperative complications in patients with OSA.

Risk Factors for Postoperative Ileus after Scoliosis Surgery

INTRODUCTION

One complication after scoliosis surgery is ileus; however, few reports have described the frequency of and risk factors for this complication. We conducted a retrospective clinical study with logistic regression analysis to confirm the frequency of and risk factors for ileus after scoliosis surgery.

METHODS

After a retrospective review of data from patients who underwent surgical correction of spinal deformity from 2009 to 2014, 110 cases (age range, 4-73 yr; median, 14 yr) were included in the study. We defined postoperative ileus (POI) as a surgical complication characterized by decreased intestinal peristalsis and the absence of stool for more than 3 days postoperatively. Various parameters were compared between patients with POI and those without POI. Logistic regression analysis was performed to assess the risk factors associated with ileus; a P value of <0.05 was considered statistically significant.

RESULTS

Fifteen of 110 (13.6%) cases developed POI. The median height, weight, operation time, and blood loss volume of the patients with versus without POI were 146 versus 152 cm, 39.0 versus 44.0 kg, 387 versus 359 min, and 1590 versus 1170 g, respectively. There were no significant differences between patients with versus without POI in the measured parameters, with the exception of patient height, bed rest period, and presence of neuromuscular scoliosis. Multiple logistic regression analysis revealed neuromuscular scoliosis as a significant risk factor for POI (odds ratio, 4.21; 95% CI, 1.23-14.40).

CONCLUSIONS

Our findings indicate a high probability of POI after scoliosis surgery, with an incidence of 13.6%. Neurogenic scoliosis, but not lowest instrumented vertebra or correction rate, was a risk factor for POI after scoliosis surgery. Digestive symptoms should be carefully monitored after surgery, particularly in patients with neuromuscular scoliosis.

Proposal of a new classification of postoperative ileus based on its clinical impact-results of a global survey and preliminary evaluation in colorectal surgery

PURPOSE

There is no consensual definition of postoperative ileus (POI), which leads to a lack of reproducibility. The aims of this study were (i) to propose and evaluate a classification of postoperative ileus based on its consequences and (ii) to assess the reproducibility of the classification.

METHODS

A national global survey was carried out according to the DELPHI method in order to create a classification of primary POI. The classification was subsequently tested on a cohort of patients who underwent colorectal surgery. Finally, a reproducibility test was performed in five teaching hospitals with junior and senior surgeons.

RESULTS

A five-stage classification was proposed: grade A (least) to grade E (worst). For better differentiation, subcategories (D1/D2) were included. Overall, 173 patients were included who underwent colorectal surgery. Forty of them experienced primary postoperative ileus (23.1%). Grade A occurred in 10 cases, grade B in 10 cases, grade C in 14 cases, grade D1 in 2 cases, and grade D2 in 2 cases. POI-related death (grade E) occurred in 2 cases. Patients with grade A POI recovered their gastrointestinal function significantly faster than those with higher grades (p = 0.01), and were more likely to undergo laparoscopic surgery (p = 0.04). The Intraclass Correlation Coefficient (ICC) was 0.83 in the overall population, and 0.83 and 0.82 respectively in the junior and senior surgeon populations.

CONCLUSION

This classification is easy to both use and reproduce. It will improve the reproducibility, evaluation, and assessment of POI. These preliminary results should be confirmed in a multi-centric international study.

Antacid attenuates the laxative action of magnesia in cancer patients receiving opioid analgesic

OBJECTIVE

This study was designed to investigate pharmacological interaction between magnesium laxative and antacid in patients receiving opioid analgesic.

METHODS

Data obtained from a total of 441 eligible patients receiving opioid analgesic for the first time were retrospectively analysed. The incidence of constipation, defined as stool-free interval of 3 days and more within the first week of opioid intake, was compared between patients who took laxative alone and those who received laxative in combination with antacid.

KEY FINDINGS

Laxatives were prescribed in 74% of patients, among them 61% received antacids such as proton pump inhibitor and H2 receptor blocker. Magnesia was the most commonly used laxative (89%). Constipation occurred in 21% and 55% of patients with and without laxatives, respectively. Antacids reversed the laxative action of lower doses (<2000 mg/day) but not higher doses (>2000 mg/day) of magnesia without affecting the effects of other laxatives. Therefore, it is suggested that both acid-dependent and acid-independent mechanisms may operate in the laxative action of magnesia, in which the former may be involved in the action of lower doses of magnesia.

CONCLUSION

Care should be taken to avoid the unfavourable pharmacological interaction between low doses of magnesia and antacid.