Postoperative Ileus--More than Just Prolonged Length of Stay?

Truly Inevitable-Our Perspective on the Complications After Surgery for Rectal Cancer

Rectal cancer is one of the most common malignancies in the GI tract. Although recent technology and treatments are available today, complications are still there. The focus of this study is to draw attention towards the important complications and their management options in rectal cancer surgeries. Retrospective study of 57 patients diagnosed and operated with rectal cancer between 2012 and 2022 using questionnaire data. 21.05% developed complications following surgery for rectal cancer including SSI, LARS, anastomosis leak, and stomal stenosis. LARS was seen in 26.31% out of the 19 patients involved in the study (LAR + ULAR) of which 80% had minor LARS scores and 20% had major LARS scores. In LARS, 80% had received long-term chemoradiotherapy in a neoadjuvant setting. The study revealed a rising trend of rectal cancer in young individuals (35.08%). Complications are an inevitable part of rectal cancer surgery even with recent technology. Use of long-course radiotherapy in neoadjuvant settings and LAR and ULAR may improve sphincter preservation with the risk of increasing incidence of low anterior resection syndrome, and anastomosis leak should be used cautiously with proper patient selection.

Effect of Probiotics on Improving Intestinal Mucosal Permeability and Inflammation after Surgery

Background/Aims

We explored the mechanisms underlying the improvement of postoperative ileus (POI) following probiotic pretreatment. We assessed intestinal permeability, inflammation, tight junction (TJ) protein expression in the gut epithelium, and plasma interleukin (IL)-17 levels in a guinea pig model of POI.

Methods

Guinea pigs were divided into control, POI, and probiotic groups. The POI and probiotic groups underwent surgery, but the probiotic group received probiotics before the procedure. The ileum and proximal colon were harvested. Intestinal permeability was measured via horseradish peroxidase permeability. Inflammation was evaluated via leukocyte count in the intestinal wall muscle layer, and calprotectin expression in each intestinal wall layer was analyzed immunohistochemically. TJ proteins were analyzed using immunohistochemical staining, and plasma IL-17 levels were measured using an enzyme-linked immunosorbent assay.

Results

The POI group exhibited increased intestinal permeability and inflammation, whereas probiotic pretreatment reduced the extent of these POI-induced changes. Probiotics restored the expression of TJ proteins occludin and zonula occludens-1 in the proximal colon, which were increased in the POI group. Calprotectin expression significantly increased in the muscle layer of the POI group and was downregulated in the probiotic group; however, no distinct differences were observed between the mucosal and submucosal layers. Plasma IL-17 levels did not significantly differ among the groups.

Conclusions

Probiotic pretreatment may relieve POI by reducing intestinal permeability and inflammation and TJ protein expression in the gut epithelium. These findings suggest a potential therapeutic approach for POI management.

Relationship of frailty and postoperative complications in older people who underwent radical surgery for a gastrointestinal tumour

OBJECTIVE

Frailty is associated with postoperative complications in older people with gastrointestinal malignancies. However, the relationship between frailty and complication severity, as well as the risk factors for complications after radical surgery, is still unclear.

METHODS

Frailty was assessed using a modified Frailty Index (mFI) score, and the correlation between frailty and postoperative complications was compared between frail and non-frail groups. Complication severity was evaluated using the Clavien-Dindo (C-D) system, and independent risk factors for postoperative complications were identified through odds ratios (OR) using multivariate logistic analysis. The participants were divided into non-frailty and frailty groups based on the mFI.

RESULTS

The frailty group had fewer patients aged 60-69 years (19% vs. 31%, p = .03) and a higher incidence of moderate CCI (52% vs. 69%, p = .001). Frailty was strongly linked to postoperative complications, including pulmonary infections (16% vs. 8%, p = .009), pulmonary embolism (8% vs. 3%, p = .02) and acute kidney injury (14% vs. 6%, p = .005). Older frail patients experienced more severe complications, with higher rates of C-D grade III (23% vs. 10%, p = .004) and grade V (6% vs. 1%, p = .004). Multivariate analysis found that frailty (OR: 1.492, p = .02), age greater than 70 years (OR: 1.239, p = .04) and severe comorbidities increased the OR of severe complications. Additionally, frail patients had poorer recovery, with higher in-hospital mortality (4% vs. 0%, p = .01), more ICU readmissions (11% vs. 3%, p = .005), longer stays (9 vs. 8 days, p < .001) and higher costs (48,035 RMB vs. 43,792 RMB, p < .001).

CONCLUSIONS

Older frail adults experienced more severe complications and had worse postoperative recovery.

Outcomes of Colectomy for Nonmalignant Polyps and Colon Cancer: A Propensity Score-Matched Analysis

INTRODUCTION

In the United States, while most nonmalignant polyps are effectively treated through endoscopic removal, colectomy remains a treatment option for selected cases of nonmalignant polyps (NMPs) and colon cancer. This study aimed to compare postoperative outcomes for colectomies in these two conditions, hypothesizing similar complication rates.

METHODS

We conducted a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database from 2015 to 2021, including patients who underwent elective colectomies for colon cancer or NMPs. Using a 2:1 propensity score matching for demographics, American Society of Anesthesiologists classification, surgical methods, and comorbidities, we evaluated outcomes such as 30-d mortality, complications, anastomotic leakage, and hospital stay duration.

RESULTS

A total of 47,960 patients, including 30,549 colon cancer patients and 17,411 NMP patients, were included after propensity score matching analysis. We concluded that there was no significant difference in mortality and reoperation rates which were 0.6% and 3.3% in patients undergoing colectomy with colon cancer, compared to 0.5% and 3.1% in those with NMP, respectively [P = 0.64, P = 0.21,]. In addition, the anastomotic leak rates were remarkably similar in both the colon cancer (2.4%) and NMP (2.2%) groups. [P = 0.13]. Most of the 30-d postoperative surgical complications, such as sepsis, septic shock, wound disruption, and urinary tract infection exhibited similar incidence rates, however, some of them, such as readmission, pulmonary embolism, and length of stay, varied between the groups.

CONCLUSIONS

Our findings underscore the similar postoperative outcomes between colon cancer and NMP groups, advocating for consideration of advanced endoscopic techniques for NMPs to potentially enhance patient care and outcomes.

Effect of perioperative dexmedetomidine on recovery of postoperative gastrointestinal function in patients with general anesthesia: a systematic review and meta-analysis

BACKGROUND

There is controversy surrounding the influence of dexmedetomidine on the recovery of postoperative gastrointestinal dysfunction in patients under general anesthesia. The main purpose of this meta-analysis is to evaluate the effect of dexmedetomidine administration during the perioperative period on the recovery of gastrointestinal function in patients under general anesthesia.

METHODS

A systematic review and meta-analysis with trial sequential analysis was performed to identify randomized controlled trials comparing dexmedetomidine administration with placebo for the recovery of gastrointestinal function. The primary outcomes were gastrointestinal function; first oral feeding time; incidences of postoperative nausea and vomiting, postoperative nausea, and postoperative vomiting; time to first bowel sound; time to first flatus; and time to first defecation. The secondary outcome was the length of hospital stay.

RESULTS

A total of 20 studies comparing 2,470 participants were included in this meta-analysis. Perioperative dexmedetomidine administration did not result in a significant reduction in the time to first oral feeding (MD= -7.91, 95% CI = - 16.45 to 0.62, P = 0.07). However, dexmedetomidine administration was associated with a decreased incidence of postoperative nausea and vomiting (RR = 0.72, 95% CI = 0.58 to 0.88, P = 0.001), time to first flatus (MD= -6.73, 95% CI= -10.31 to -3.15, P = 0.0002), and time to first defecation (MD= -12.01, 95% CI = -22.40 to -1.61, P = 0.02).

CONCLUSIONS

Perioperative dexmedetomidine administration can promote the recovery of gastrointestinal function and reduce the length of hospital stay after abdominal surgery. The optimal dose and timing of dexmedetomidine and the influence on non-abdominal surgery need further investigation.

TRIAL REGISTRATION

The study protocol was registered in the PROSPERO database (registration number: CRD42023443708) on July 9, 2023.

Excess hospital length of stay and extra cost attributable to primary prolonged postoperative ileus in open alimentary tract surgery: a multicenter cohort analysis in China

BACKGROUND

Prolonged postoperative ileus (PPOI) reportedly leads to compromised postoperative recovery and increased healthcare costs. However, the evidence for this claim was obtained from studies that included patients with both primary and secondary PPOI. How primary PPOI affects the hospital length of stay (LOS) and healthcare costs is not well documented. A multicenter cohort analysis was performed to investigate the potentially detrimental effect of primary PPOI on hospital LOS and healthcare costs.

METHODS

In total, 2083 patients who underwent open abdominal surgery from 22 tertiary hospitals in China were prospectively registered in a PPOI cohort. Of these, 1863 patients without secondary PPOI were analyzed. Poisson regression for hospital LOS and log-transformed linear regression for healthcare costs were performed to identify whether primary PPOI was an independent risk factor.

RESULTS

The incidence of primary PPOI was 13.2% (246/1863). The median LOS was significantly longer in the PPOI than non-PPOI group (12 vs. 11 days, p < 0.001). The median healthcare cost was significantly higher in the PPOI than non-PPOI group (70,672 vs. 67,597 CNY, p = 0.016). Multivariate Poisson regression and log-transformed linear regression showed that 12% of prolonged LOS and 4.6% of healthcare costs were due to primary PPOI.

CONCLUSIONS

Primary PPOI is a potential source of prolonged hospital LOS and extra healthcare costs for patients undergoing open abdominal surgery. Cost-effective approaches are needed to manage and prevent primary PPOI.

Nomogram for predicting postoperative ileus after radical cystectomy and urinary diversion: a retrospective single-center study

OBJECTIVE

To predict the incidence of postoperative ileus in bladder cancer patients after radical cystectomy.

METHODS

We retrospectively analyzed the perioperative data of 452 bladder cancer patients who underwent radical cystectomy with urinary diversion at the Second Hospital of Tianjin Medical University between 2016 and 2021. Univariate and multivariate logistic regression were used to identify the risk factors for postoperative ileus. Finally, a nomogram model was established and verified based on the independent risk factors.

RESULTS

Our study revealed that 96 patients (21.2%) developed postoperative ileus. Using multivariate logistic regression analysis, we found that the independent risk factors for postoperative ileus after radical cystectomy included age > 65.0 years, high or low body mass index, constipation, hypoalbuminemia, and operative time. We established a nomogram prediction model based on these independent risk factors. Validation by calibration curves, concordance index, and decision curve analysis showed a strong correlation between predicted and actual probabilities of occurrence.

CONCLUSION

Our nomogram prediction model provides surgeons with a simple tool to predict the incidence of postoperative ileus in bladder cancer patients undergoing radical cystectomy.

Effect of Alvimopan on Postoperative Ileus and Length of Hospital Stay in Patients Undergoing Bowel Resection: A Systematic Review and Meta-Analysis

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.

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.

Efficacy of Wuda Granule on Recovery of Gastrointestinal Function after Laparoscopic Bowel Resection: A Randomized Double-Blind Controlled Trial

OBJECTIVE

To evaluate the efficacy and safety of Wuda Granule (WDG) on recovery of gastrointestinal function after laparoscopic bowel resection in the setting of enhanced recovery after surgery (ERAS)-based perioperative care.

METHODS

A total of 108 patients aged 18 years or older undergoing laparoscopic bowel resection with a surgical duration of 2 to 4.5 h were randomly assigned (1:1) to receive either WDG or placebo (10 g/bag) twice a day from postoperative days 1-3, combining with ERAS-based perioperative care. The primary outcome was time to first defecation. Secondary outcomes were time to first flatus, time to first tolerance of liquid or semi-liquid food, gastrointestinal-related symptoms and length of stay. Subgroup analysis of the primary outcome according to sex, age, tumor site, surgical time, histories of underlying disease or history of abdominal surgery was undertaken. Adverse events were observed and recorded.

RESULTS

A total of 107 patients [53 in the WDG group and 54 in the placebo group; 61.7 ± 12.1 years; 50 males (46.7%)] were included in the intention-to-treat analysis. The patients in the WDG group had a significantly shorter time to first defecation and flatus [between-group difference -11.01 h (95% CI -20.75 to -1.28 h), P=0.012 for defecation; -5.41 h (-11.10 to 0.27 h), P=0.040 for flatus] than the placebo group. Moreover, the extent of improvement in postoperative gastrointestinal-related symptoms in the WDG group was significantly better than that in the placebo group (P<0.05). Subgroup analyses revealed that the benefits of WDG were significantly superior in patients who were male, or under 60 years old, or surgical time less than 3 h, or having no history of basic disease or no history of abdominal surgery. There were no serious adverse events.

CONCLUSION

The addition of WDG to an ERAS postoperative care may be a viable strategy to enhance gastrointestinal function recovery after laparoscopic bowel resection surgery. (Registry No. ChiCTR2100046242).

For whom the bell tolls: assessing the incremental costs associated with failure to rescue after elective colorectal surgery

BACKGROUND

Failure to rescue after elective surgery is associated with increased healthcare costs. These costs are poorly understood and have not been reported for colorectal surgery. This study aimed to assess the incremental costs of failure to rescue after elective colorectal surgery.

METHODS

This was a retrospective study of adult patients identified in the National Inpatient Sample from 2016 to 2019 who underwent an elective colectomy or proctectomy. Patients were stratified into 4 groups: uneventful recovery, successfully rescued, failure to rescue, and died without rescue attempts. "Rescue" was defined as admissions with ≥1 procedure code ≥1 day after the initial procedure. The primary outcome was total admission costs.

RESULTS

Of 451,490 admissions for elective colorectal resection, 94.6% had an uneventful recovery, 4.8% were successfully rescued, 0.4% were failure to rescue, and 0.3% died without rescue attempts. The median total hospital cost for the uneventful recovery cohort was $16,751 (IQR, $12,611-$23,116), for the successfully rescued cohort was $42,295 (IQR, $27,959-$67,077), for the failure-to-rescue cohort was $53,182 (IQR, $30,852-$95,615), and for the died without attempted rescue cohort was $29,296 (IQR, $19,812-$45,919). When comparing cost quantiles by regression analysis, failure-to-rescue patients had significantly higher costs than the successfully rescued patients for the last 3 quantiles (fifth quantile [90th percentile], $163,963 vs $106,521; P < .001).

CONCLUSION

Across a nationally representative cohort, the median total hospital costs for patients who failed to be rescued were $10,887 more than for those who were successfully rescued. These findings emphasize the importance of shared decision making and medical futility and highlight opportunities for resource optimization after postoperative complications.

The Effect of CKD-495, Eupacidin, and Their Marker Compounds on Altered Permeability in a Postoperative Ileus Animal Model

Background and Objectives: Postoperative ileus (POI) is a delay in gastrointestinal transit following surgery that leads to various complications. There is limited understanding of its effective treatment options. CKD-495 and eupacidin are natural products licensed for treating mucosal lesions in acute and chronic gastritis; however, little is known about their effects on intestinal permeability. This study evaluated the effects of CKD-495, eupacidin, and its components (eupatilin and cinnamic acid) on intestinal permeability in an animal model of POI. Materials and Methods: Guinea pigs underwent surgical procedures and were randomly assigned to different treatment groups. Drugs were administered orally prior to surgery. Intestinal permeability, leukocyte count, and the expression of calprotectin and tight junction proteins were measured in the harvested ileum tissue. Results: The intestinal permeability and leukocyte count were higher in the POI group than in the control group. The pre-administration of CKD-495, cinnamic acid, eupacidin, and eupatilin effectively prevented these changes in the POI model. No significant differences were observed in the expression of tight junction proteins. Conclusions: CKD-495, cinnamic acid, eupacidin, and eupatilin exerted protective effects against increased intestinal permeability and inflammation in an animal model of POI. These natural products have potential as therapeutic options for the treatment of POI.

Alvimopan for postoperative ileus following abdominal surgery: a systematic review

BACKGROUND

Postoperative ileus (POI) is a common complication following abdominal surgery, often leading to extended hospital stays and a higher risk of post-operative complications, leading to poorer patient outcomes. Alvimopan, a peripherally acting µ-opioid receptor antagonist, has been shown to aid in the recovery of normal bowel function after surgery. While its benefits are well-established in open abdominal surgeries, its efficacy in laparoscopic procedures had not been conclusively determined. However, recent clinical trials involving laparoscopic surgeries have since been conducted. This review aims to reassess the efficacy of Alvimopan by incorporating findings from these new studies, potentially providing further insight into its clinical benefits.

METHODS

A comprehensive search of PubMed, Google Scholar, EMBASE, and the Cochrane Library was conducted. Studies were included based on the PICO framework, focusing on Alvimopan's impact on postoperative gastrointestinal recovery. Primary outcomes were time to gastrointestinal function recovery (GI-3) and hospital stay duration.

RESULTS

Ten studies met the inclusion criteria, with seven focusing on the use of Alvimopan in open abdominal surgeries and three in laparoscopic procedures. Collectively, these studies involved 18,822 patients undergoing various types of abdominal Administration of Alvimopan 6 mg accelerated gastrointestinal function recovery by an average of 14 h (Hazard ratio: 1.62, p = 0.002) and reduced hospital stays by 5.2 h (Hazard ratio: 1.52, p = 0.04) compared to placebo. Similarly, Alvimopan 12 mg reduced GI-3 recovery time by 13.5 h (Hazard ratio: 1.58, p = 0.02) and hospital stay duration by 6.2 h (Hazard ratio: 1.46, p = 0.018).

CONCLUSION

Alvimopan shows promise in reducing POI and hospital stay durations following abdominal surgeries. The incorporation of the recent studies in laparoscopic abdominal procedures further supports these findings. Integrating Alvimopan into perioperative care protocols may enhance patient outcomes and help lower healthcare costs.

Postoperative Multimodal Analgesia Strategy for Enhanced Recovery After Surgery in Elderly Colorectal Cancer Patients

Enhanced Recovery After Surgery (ERAS) protocols have substantially proven their merit in diminishing recuperation durations and mitigating postoperative adverse events in geriatric populations undergoing colorectal cancer procedures. Despite this, the pivotal aspect of postoperative pain control has not garnered the commensurate attention it deserves. Typically, employing a multimodal analgesia regimen that weaves together nonsteroidal anti-inflammatory drugs, opioids, local anesthetics, and nerve blocks stands paramount in curtailing surgical complications and facilitating reduced convalescence within hospital confines. Nevertheless, this integrative pain strategy is not devoid of pitfalls; the specter of organ dysfunction looms over the geriatric cohort, rooted in the abuse of analgesics or the complex interplay of polypharmacy. Revolutionary research is delving into alternative delivery and release modalities, seeking to allay the inadvertent consequences of analgesia and thereby potentially elevating postoperative outcomes for the elderly post-colorectal cancer surgery populace. This review examines the dual aspects of multimodal analgesia regimens by comparing their established benefits with potential limitations and offers insight into the evolving strategies of drug administration and release.

Evaluation of postoperative results after a presurgical optimisation programme

BACKGROUND

Presurgical optimisation programmes decrease the risk of postoperative complications, reduce hospital stays and speed up patient recovery. They usually involve a multidisciplinary team addressing physical, nutritional and psychosocial issues. The objective of this study was to assess the results of implementing a presurgical optimisation programme led by a liaison nurse in patients undergoing major surgery in a primary general hospital.

METHODS

An observational, retrospective, descriptive, cross-sectional, comparative study based on the revision of patients' health records undergoing major surgery between January 2019 and December 2022. Patients entering the presurgical optimisation programme (intervention group) were compared with patients receiving usual medical care (control group). The presurgical optimisation programme consisted of oral nutritional supplementation, physical exercise, strengthening of lung capacity and psychological and emotional support. Frequency (%) of surgery complications and use of healthcare resources (duration of hospitalisation, time spent in the intensive care unit (ICU), and readmission) at day 30 were recorded. Descriptive statistics were applied.

RESULTS

Two hundred eleven patients (58.5% men, mean age: 65.76 years (SD 11.5), 75.2%. non-smokers; mean body mass index (BMI): 28.32 (SD 5.38); mean Nutritional Risk Score (NRS) 3.71 (SD 1.35; oncology diagnosis: 88.6%) were included: 135 in the intervention group, and 76 in the control group. The average duration of the presurgical optimisation programme was 20 days (SD 5). Frequency of postoperative complications was 25% (n = 33) in the intervention group and 52.6% (n = 40) in the control group (p < 0.001) [odds ratio (OR) = 3.4; 95% confidence interval (CI) (1.8; 6.2)]. 14.5% (n = 19) of patients in the intervention group and 34.2% (n = 26) in the control group had remote postoperative complications [OR = 3.1; 95% CI (1.6; 6.2)]. Patients in the intervention group spent fewer days in the hospital [mean 8.34 (SD 6.70) vs 11.63 (SD 10.63)], and there were fewer readmissions at 30 days (7.6% vs 19.7%) compared with the control group.

CONCLUSIONS

A presurgical optimisation programme led by a liaison nurse decreases the rate of immediate and late surgical complications and reduces hospital stays and readmissions in patients undergoing major surgery.

Prucalopride and Bowel Function Post Gastrointestinal Surgery: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Prolonged postoperative ileus (PPOI) contributes to morbidity and prolonged hospitalization. Prucalopride, a selective 5-hydroxytryptamine receptor agonist, may enhance bowel motility. This review assesses whether the perioperative use of prucalopride compared to placebo is associated with accelerated return of bowel function post gastrointestinal (GI) surgery.

METHODS

OVID, CENTRAL, and EMBASE were searched as of January 2024 to identify randomized controlled trials (RCTs) comparing prucalopride and placebo for prevention of PPOI in adult patients undergoing GI surgery. The primary outcomes were time to stool, time to flatus, and time to oral tolerance. The secondary outcomes were incidence of PPOI, length of stay (LOS), postoperative complications, adverse events, and overall costs. The Cochrane risk of bias tool for randomized trials and the Grading of Recommendations, Assessment, Development, and Evaluations framework were used. An inverse variance random effects model was used.

RESULTS

From 174 citations, 3 RCTs with 139 patients in each treatment group were included. Patients underwent a variety of GI surgeries. Patients treated with prucalopride had a decreased time to stool (mean difference 36.82 hours, 95% CI 59.4 to 14.24 hours lower, I2 = 62%, low certainty evidence). Other outcomes were not statistically significantly different (very low certainty evidence). Postoperative complications and adverse events could not be meta-analyzed due to heterogeneity; yet individual studies suggested no significant differences (very low certainty evidence).

DISCUSSION

Current RCT evidence suggests that prucalopride may enhance postoperative return of bowel function. Larger RCTs assessing patient important outcomes and associated costs are needed before routine use of this agent.

Improved Postoperative Pain Management Outcomes After Implementation of Enhanced Recovery After Surgery (ERAS) Protocol for Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS-HIPEC)

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for patients with peritoneal carcinomatosis is promising but has potential for significant morbidity and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a standardized protocol designed to optimize perioperative care. This study describes trends in epidural and opioid use after implementing ERAS for CRS-HIPEC at a tertiary academic center.

METHODS

A retrospective analysis of patients undergoing CRS-HIPEC from January 2020 to September 2023 was conducted. ERAS was implemented in February 2022. Medication and outcomes data were compared before and after ERAS initiation. All opioids were converted to morphine milligram equivalents (MMEs).

RESULTS

A total of 136 patients underwent CRS-HIPEC: 73 (54%) pre- and 63 (46%) post-ERAS. Epidural usage increased from 63% pre-ERAS to 87% post-ERAS (p = 0.001). Compared with those without epidurals, patients with epidurals had decreased total 7-day oral and intravenous (IV) opioid requirements (45 MME vs. 316 MME; p < 0.001). There was no difference in 7-day opioid totals between pre- and post-ERAS groups. After ERAS, more patients achieved early ambulation (83% vs. 53%; p < 0.001), early diet initiation (81% vs. 25%; p < 0.001), and early return of bowel function (86% vs. 67%; p = 0.012).

CONCLUSIONS

ERAS implementation for CRS-HIPEC was associated with increased epidural use, decreased oral and IV opioid use, and earlier bowel function return. Our study demonstrates that epidural analgesia provides adequate pain control while significantly decreasing oral and IV opioid use, which may promote gastrointestinal recovery postoperatively. These findings support the implementation of an ERAS protocol for effective pain management in patients undergoing CRS-HIPEC.

Risk prediction algorithms for prolonged postoperative ileus: A systematic review

AIM

Prolonged postoperative ileus (PPOI) is common and is associated with a significant healthcare burden. Previous studies have attempted to predict PPOI clinically using risk prediction algorithms. The aim of this work was to systematically review and compare risk prediction algorithms for PPOI following colorectal surgery.

METHOD

A systematic literature search was conducted using MEDLINE, Embase, Web of Science and CINAHL Plus. Studies that developed and/or validated a risk prediction algorithm for PPOI in adults following colorectal surgery were included. Data were collected on study design, population and operative characteristics, the definition of PPOI used and risk prediction algorithm design and performance. Quality appraisal was assessed using the PROBAST tool.

RESULTS

Eleven studies with 87 549 participants were included in our review. Most were retrospective, single-centre analyses (6/11, 55%) and rates of PPOI varied from 10% to 28%. The most commonly used variables were sex (8/11, 73%), age (6/11, 55%) and surgical approach (5/11, 45%). Area under the curve ranged from 0.68-0.78, and only three models were validated. However, there was significant variation in the definition of PPOI used. No study reported sensitivity, specificity or positive/negative predictive values.

CONCLUSION

Currently available risk prediction algorithms for PPOI appear to discriminate moderately well, although there is a lack of validation data. Future studies should aim to use a standardized definition of PPOI, comprehensively report model performance and validate their findings using internal and external methodologies.

Comparison of three frailty scales for prediction of prolonged postoperative ileus following major abdominal surgery in elderly patients: a prospective cohort study

BACKGROUND

To determine whether frailty can predict prolonged postoperative ileus (PPOI) in older abdominal surgical patients; and to compare predictive ability of the FRAIL scale, the five-point modified frailty index (mFI-5) and Groningen Frailty Indicator (GFI) for PPOI.

METHODS

Patients (aged ≥ 65 years) undergoing major abdominal surgery at our institution between April 2022 to January 2023 were prospectively enrolled. Frailty was evaluated with FRAIL, mFI-5 and GFI before operation. Data on demographics, comorbidities, perioperative management, postoperative recovery of bowel function and PPOI occurrence were collected.

RESULTS

The incidence of frailty assessed with FRAIL, mFI-5 and GFI was 18.2%, 38.4% and 32.5% in a total of 203 patients, respectively. Ninety-five (46.8%) patients experienced PPOI. Time to first soft diet intake was longer in patients with frailty assessed by the three scales than that in patients without frailty. Frailty diagnosed by mFI-5 [Odds ratio (OR) 3.230, 95% confidence interval (CI) 1.572-6.638, P = 0.001] or GFI (OR 2.627, 95% CI 1.307-5.281, P = 0.007) was related to a higher risk of PPOI. Both mFI-5 [Area under curve (AUC) 0.653, 95% CI 0.577-0.730] and GFI (OR 2.627, 95% CI 1.307-5.281, P = 0.007) had insufficient accuracy for the prediction of PPOI in patients undergoing major abdominal surgery.

CONCLUSIONS

Elderly patients diagnosed as frail on the mFI-5 or GFI are at an increased risk of PPOI after major abdominal surgery. However, neither mFI-5 nor GFI can accurately identify individuals who will develop PPOI.

TRIAL REGISTRATION

This study was registered in Chinese Clinical Trial Registry (No. ChiCTR2200058178). The date of first registration, 31/03/2022, https://www.chictr.org.cn/ .

Comparing return of bowel function after right versus extended right hemicolectomy: a retrospective analysis

BACKGROUND

Prolonged postoperative ileus (PPOI) is associated with higher morbidity and extended inpatient stay. Although evidence suggests that PPOI is more common following right-sided resections, it is uncertain if return to bowel function is similar following extended right (ERH) versus right hemicolectomy (RH).

METHODS

The recovery of patients undergoing ERH and RH in a regional hospital in New Zealand was retrospectively compared, from 2012 to 2021. Rates of PPOI, return of bowel function and postoperative complications were compared. Other factors potentially relating to PPOI were analysed.

RESULTS

293 patients were included (42 who underwent ERH, and 251 RH). PPOI was more common following ERH than RH (43% vs. 25%, P = 0.02). When accounting for the operative approach, rate of PPOI was not significantly different (42% open ERH vs. 36% open RH; P = 0.56). Excluding PPOI, return of bowel function did not differ between groups. Patient undergoing ERH versus RH had significantly higher length of stay (1 day) and Hb drop (2.5 g/L) postoperatively.

CONCLUSION

Higher rates of PPOI have been demonstrated in ERH versus RH however when controlling for approach, there was not a significant difference. Further interrogation into rates of PPOI (particularly after laparoscopic surgery) are warranted to tailor locoregional ERAS protocols.

Prediction of the risk of severe small bowel obstruction and effects of Houpu Paiqi mixture in patients undergoing surgery for small bowel obstruction

AIM

Small bowel obstruction is a common condition that requires emergency surgery. Slow recovery of bowel function after surgery or the occurrence of one or more complications can exacerbate the disease and result in severe small bowel obstruction (SSBO), significantly impacting recovery. It is characterized by a failure to regain enteral nutrition promptly, requiring long-term intensive care. Therefore, it is necessary to identify factors that predict SSBO, to allow early intervention for patients likely to develop this condition.

METHODS

Of the 260 patients who underwent emergency or elective surgery for small bowel obstruction between January 2018 and December 2022, 45 developed SSBO. The least absolute shrinkage and selection operator regression model was applied to optimize factor selection and multivariable logistic regression analysis was used to construct a predictive model. The performance and clinical utility of the nomogram were determined and internal validation was conducted. In addition, the effects of the Houpu Paiqi mixture on postoperative recovery were analyzed by comparing the clinical data of 28 patients who were treated with the mixture and 61patients who did not receive it.

RESULTS

The predictors included in the prediction nomogram were age, peritonitis, intestinal resection and anastomosis, complications, operation time, Acute Physiology and Chronic Health Evaluation II score, white blood cell count, and procalcitonin level. The model had an area under the receiver operating characteristic curve of 0.948 (95% confidence interval: 0.814-0.956). Decision curve analysis demonstrated that the SSBO risk nomogram had a good net clinical benefit. In addition, treatment with the Houpu Paiqi mixture reduced postoperative exhaust time, postoperative defecation time, time to first postoperative liquid feed, and length of stay in hospital.

CONCLUSIONS

We developed a nomogram that can assist clinicians in identifying patients at greater risk of SSBO, which may aid in early diagnosis and intervention. Additionally, we found that the Houpu Paiqi mixture promoted postoperative recovery.

ILEOSTIM trial: a study protocol to evaluate the effectiveness of efferent loop stimulation before ileostomy reversal

PURPOSE

A protective loop ileostomy is the most useful method to reduce sequelae in the event of an anastomotic leakage (AL) after rectal cancer surgery. However, it requires an additional stoma reversal surgery with its own potential complications. Postoperative ileus (POI) remains the most common complication after ileostomy reversal, which leads to an increase in morbidity, length of hospital stay (LOS) and overall healthcare costs. Several retrospective studies carried out in this field have concluded that there are insufficient evidence-based recommendations about the routine application of preoperative bowel stimulation in clinical practice. Here we discuss whether stimulation of the efferent limb before ileostomy reversal might reduce POI and improve postoperative outcomes.

METHODS

This is a multicentre randomised controlled trial to determine whether mechanical stimulation of the efferent limb during the 2 weeks before the ileostomy reversal would help to reduce the development of POI after surgery. This study was registered on Clinicaltrials.gov (NCT05302557). Stimulation will consist of infusing a solution of 500 ml of saline chloride solution mixed with a thickening agent (Resource©, Nestlé Health Science; 6.4 g sachet) into the distal limb of the ileostomy loop. This will be performed within the 2 weeks before ileostomy reversal, in an outpatient clinic under the supervision of a trained stoma nurse.

CONCLUSION

The results of this study could provide some insights into the preoperative management of these patients.

Incidence and risk factors for postoperative gastrointestinal dysfunction occurrence after gastrointestinal procedures in US patients

BACKGROUND

Incidence of, and potential risk factors for, postoperative gastrointestinal dysfunction (POGD) after gastrointestinal procedures performed in US hospitals were examined.

METHODS

This retrospective study used hospital discharge data of inpatients who underwent ≥1 gastrointestinal procedures from 1-Jan-2016 to 30-Apr-2019. POGD incidence was calculated based on all hospitalizations for MDC-06 procedures. Predictors of POGD were assessed using multivariable logistic regression.

RESULTS

POGD incidence was 5.8% among 638 611 inpatient hospitalizations. Major bowel procedures, peritoneal adhesiolysis, and appendectomy were the most notable predictors of POGD among gastrointestinal procedures assessed (adjusted odds ratios [95% confidence intervals]: 2.71 [2.59-2.83], 2.48 [2.34-2.64], and 2.15 [2.03-2.27], respectively; all p < 0.05). Procedures performed by colorectal/gastroenterology specialists (0.86 [0.84-0.89]), and those performed percutaneously (0.55 [0.54-0.56]) were associated with significantly lower odds of POGD (both P < 0.05).

CONCLUSIONS

Findings may help clinicians tailor management plans targeting patients at high-risk of POGD.

Multiple Thrombotic, Infectious, and Cardiopulmonary Complications Following Laparoscopic Converted to Open Colectomy Procedure: A Case Report and Literature Review

All surgeries, from minor procedures, such as sutures, to major surgeries, such as open abdominal surgery, carry with them risk for complications. Among the most frequently encountered complications are surgical site infections and thrombotic complications. Less frequently, cardiac complications such as atrial fibrillation are seen. In this case report, we discuss the various complications encountered during the hospital stay of a 61-year-old male following a laparoscopic converted to open colectomy procedure for the treatment of a colorectal mass. Following surgery, a surgical pathology report revealed a newly diagnosed stage 3b colorectal adenocarcinoma. Multiple abscesses in the abdominopelvic cavity were discovered on computed tomography (CT), revealing a major surgical site infectious process. These findings warranted emergent surgical intervention and placement of multiple Jackson-Pratt drains. Due to previously untreated carcinoma promoting a prothrombotic state, the patient developed numerous thrombotic complications such as segmental pulmonary embolism, superior mesenteric vein thrombosis, and superficial thrombophlebitis of the saphenous veins. He also developed new-onset paroxysmal atrial fibrillation secondary to postoperative pain, as well as bilateral pleural effusions. Here, we shed light on the mechanisms of development of such complications, as well as the management and methods for prevention.

Coffee administration to promote return of bowel function after small bowel resection: A randomized, controlled trial

BACKGROUND

Prolonged ileus occurs in 10%-24% of patients undergoing abdominal surgery. Several trials have found coffee administration reduces postoperative ileus, but this has not been evaluated for small bowel resection.

METHODS

Following small bowel resection, patients were randomized to caffeinated coffee or warm water three times a day until the time of first flatus or first bowel movement. Primary outcomes were time from end of procedure to: 1) nasogastric tube removal; and 2) when the discharge order was written. Outcomes were compared using Kaplan-Meier survival curves.

RESULTS

Thirty-nine patients received coffee and 40 water. Median days to nasogastric tube removal was 3.4 for the coffee and 4.0 for the water groups (p = 0.002). Median days to discharge order was 6.7 for the coffee and 7.7 for the water groups (p = 0.01).

CONCLUSION

Coffee was safe and decreased time to nasogastric tube removal and hospital stay in patients undergoing small bowel resection.

Does coffee affect bowel recovery following minimally invasive colorectal operations? A three-armed randomized controlled trial

PURPOSE

Previous studies have suggested that coffee may shorten the postoperative ileus period. We sought to evaluate the impact of both coffee and caffeine on shortening the return of postoperative bowel function following minimally invasive colectomy.

METHODS

This was a single-center, randomized controlled clinical trial conducted in a tertiary hospital. Patients undergoing an elective robotic or laparoscopic small or large bowel operation were included in this study. Patients were randomized into one of three groups: warm water, decaffeinated coffee, and caffeinated coffee. Subjects were assigned to drink a 4-oz cup three times daily starting on postoperative day one. The primary endpoint was time to first bowel movement. Secondary endpoints included time to first flatus, length of hospital stay, and postoperative morbidity.

RESULTS

A total of 99 patients were included in this study: 31 warm water, 31 decaffeinated coffee, and 37 caffeinated coffee. The groups were similar in age and sex (p = 0.51 and 0.91, respectively). Mean (SD) time to the first bowel movement in days was 2.94 (1.4), 2.58 (1.2), and 2.86 (1.3), respectively (p = 0.53). There were no significant differences observed in postoperative morbidity (p = 0.52) between groups. Multivariate linear regression analysis did not reveal a statistically significant association between any interventions and time to first bowel movement or length of hospital stay.

CONCLUSIONS

Coffee (caffeinated or decaffeinated) does not expedite the return of bowel function following minimally invasive operation.

TRIAL REGISTRATION

https://classic.

CLINICALTRIALS

gov/ct2/show/NCT02639728 NCT02639728.

The Postoperative Effect of Sugammadex versus Acetylcholinesterase Inhibitors in Colorectal Surgery: An Updated Meta-Analysis

BACKGROUND

the aim of this meta-analysis was to evaluate the postoperative effects of neuromuscular blockade reversal with sugammadex compared with acetylcholinesterase inhibitors in colorectal surgery.

METHODS

A systematic literature search was performed for studies comparing the postoperative course of patients receiving neuromuscular blockade reversal with either sugammadex or acetylcholinesterase inhibitors (control) after colorectal surgery. Data from eligible studies were extracted, qualitatively assessed, and included in a meta-analysis. Odds ratios and standardized mean differences with 95% confidence intervals (CIs) were calculated.

RESULTS

Five studies with a total of 1969 patients were included (sugammadex n = 1137, control n = 832). Sugammadex reversal resulted in a significantly faster return of defecation or flatus after surgery compared to acetylcholinesterase inhibitors (SMD 13.01, 95% CI 6.55-19.46, p = < 0.0001). There were no significant differences between the two groups in other clinical outcomes such as surgical morbidity and length of hospital stay.

CONCLUSION

The present data support the beneficial impact of sugammadex on gastrointestinal motility after colorectal surgery. However, the effect of sugammadex on the prevention of surgical complications and a prolonged hospital stay is diminishing. Larger randomized controlled trials with standardized study protocols are needed to validate the results presented here.

Surgical outcomes and prognostic factors associated with emergency left colonic surgery

BACKGROUND

Mortality from emergency left-sided colorectal surgery can be substantial due to acuteness of the presentation and the urgent need to operate in the setting of a limited preparation in a morbid patient.

OBJECTIVES

Determine the 30-day postoperative outcomes and identify risk factors for complications and mortality following emergency colorectal operations.

DESIGN

Retrospective SETTINGS: Three tertiary hospitals in three countries.

PATIENTS AND METHODS

Factors that were studied included age, sex, ASA score, type and extent of the operation, and presence/absence of malignancy. Unadjusted 30-day patient outcomes examined were complications and mortality. Differences in proportions were assessed using the Pearson chi-square test while logistic regression analyses were carried out to evaluate the correlation between risk factors and outcomes.

MAIN OUTCOME MEASURES

30-day postoperative morbidity and mortality SAMPLE SIZE: 104 patients.

RESULTS

Among 104 patients, 70 (67.3%) were men, and 34 (32.7%) were women. The mean (SD) age was 57.2 (17.1) years. The most common indication for emergency colonic surgery was malignant obstruction in 33 (31.7%) patients. The postoperative complication rate was 24% (25/104), and the mortality rate was 12.5% (13/104) within 30 days of the operation. The ASA status (P=.02), presence of malignancy (P=.02), and the presence of complications (P=.004) were significantly related to mortality in the multivariable logistic regression analysis.

CONCLUSIONS

The 30-day mortality of emergency colorectal operations is greatly influenced by the presence of malignancy in the colon and physiological status at the time of the procedure.

LIMITATIONS

The retrospective design and small sample size.

CONFLICT OF INTEREST

None.

Ileus rate after abdominal wall reconstruction: a retrospective analysis of two clinical trials

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.

Exploring the Association Between Paralytic Ileus and Endoscopic Retrograde Cholangiopancreatography Complications Using the National Inpatient Sample Database

Introduction Paralytic ileus (PI) is often seen in critically ill hospitalized patients. Those with pancreaticobiliary diseases will require endoscopic retrograde cholangiopancreatography (ERCP) for management. Here, we will explore the association between patients with paralytic ileus who underwent ERCP and post-procedural complications, which has not been done before. Methods Patients who underwent ERCP between 2007 and 2017 in the National Inpatient Sample database were selected. Cases were matched 1:1 by age, gender, race, and the Elixhauser comorbidity index for patients with and without pre-procedural paralytic ileus. Primary outcomes were associations between paralytic ileus and length of stay, payor status, and average total charges. Secondary outcomes were associations between paralytic ileus and post-ERCP complications (infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage), and overall mortality. The Chi-squared analysis was used to compare categorical data, and the independent t-test was used for continuous data. Regression analysis was used to assess primary and secondary outcomes. Results Of 2,008,217 hospitalized patients from 2007 to 2017, 43,643 patients had paralytic ileus and 43,859 patients did not, before undergoing ERCP. There were no differences in age, gender, race, or the Elixhauser comorbidity index. The differences in the length of stay, payor status, and total charges were significant (p<0.001). Patients with paralytic ileus had increased risks of post-ERCP infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage, and overall mortality (p<0.001). Conclusions Patients hospitalized with paralytic ileus who underwent ERCP had a longer length of stay, higher total charges, and were less compensable. They also had increased risks for post-ERCP infection, pancreatitis, cholangitis, cholecystitis, perforation, hemorrhage, and overall mortality, which can be from critical illness and the systemic inflammatory response.

Postoperative paralytic ileus following debulking surgery in ovarian cancer patients

Aim

This study aims to evaluate the incidence of postoperative ileus (POI) following cytoreductive surgery in epithelial ovarian cancer (EOC) patients and its impact on anastomotic leakage occurrence and postoperative complications.

Methods

A total of 357 surgeries were performed on 346 ovarian cancer patients between 1/2010 and 12/2020 at our institution. The postoperative course regarding paralytic ileus, anastomotic leakage, and postoperative complications was analyzed by Fisher's exact test and through ordinal logistic regression.

Results

A total of 233 patients (65.3%) returned to normal gastrointestinal functions within 3 days after surgery. A total of 123 patients (34.5%) developed POI. There were 199 anastomoses in 165 patients and 24 leakages (12.1%). Postoperative antibiotics (p 0.001), stoma creation (p 0.0001), and early start of laxatives (p 0.0048) significantly decreased POI, while anastomoses in general (p 0.0465) and especially low anastomoses (p 0.0143) showed increased POI rates. Intraoperative positive fluid excess >5,000 cc was associated with a higher risk for POI (p 0.0063), anastomotic leakage (p 0.0254), and severe complications (p 0.0012).

Conclusion

Postoperative antibiotics, an early start with laxatives, and stoma creation were associated with reduced POI rates. Patients with anastomoses showed an increased risk for POI. Severe complications, anastomotic leakages, and POI were more common in the case of intraoperative fluid balance exceeding 5,000 cc.

Effect of prucalopride to improve time to gut function recovery following elective colorectal surgery: randomized clinical trial

BACKGROUND

Delayed return to gut function and prolonged postoperative ileus (PPOI) delay recovery after colorectal surgery. Prucalopride is a selective serotonin-4-receptor agonist that may improve gut motility.

METHODS

This was a multicentre, double-blind, parallel, placebo-controlled randomized trial of 2 mg prucalopride versus placebo in patients undergoing elective colorectal resection. Patients with inflammatory bowel disease and planned ileostomy formation were excluded, but colostomy formation was allowed. The study medication was given 2 h before surgery and daily for up to 6 days after operation. The aim was to determine whether prucalopride improved return of gut function and reduced the incidence of PPOI. The primary endpoint was time to passage of stool and tolerance of diet (GI-2). Participants were allocated in a 1 : 1 ratio, in blocks of 10. Randomization was computer-generated. All study personnel, medical staff, and patients were blinded.

RESULTS

This study was completed between October 2017 and May 2020 at two tertiary hospitals in New Zealand. A total of 148 patients were randomized, 74 per arm. Demographic data were similar in the two groups. There was no difference in median time to GI-2 between prucalopride and placebo groups: 3.5 (i.q.r. 2-5) versus 4 (3-5) days respectively (P = 0.124). Prucalopride improved the median time to passage of stool (3 versus 4 days; P = 0.027) but not time to tolerance of diet (2 versus 2 days; P = 0.669) or median duration of hospital stay (4 versus 4 days; P = 0.929). In patients who underwent laparoscopic surgery (125, 84.5 per cent), prucalopride improved median time to GI-2: 3 (2-4) days versus 4 (3-5) days for placebo (P = 0.012). The rate of PPOI, complications, and adverse events was similar in the two groups.

CONCLUSION

Prucalopride did not improve time to overall recovery of gut function after elective colorectal surgery. Registration number: NCT02947269 (http://www.clinicaltrials.gov).

The Role of Inflammatory Mediators in the Development of Gastrointestinal Motility Disorders

Feeding intolerance and the development of ileus is a common complication affecting critically ill, surgical, and trauma patients, resulting in prolonged intensive care unit and hospital stays, increased infectious complications, a higher rate of hospital readmission, and higher medical care costs. Medical treatment for ileus is ineffective and many of the available prokinetic drugs have serious side effects that limit their use. Despite the large number of patients affected and the consequences of ileus, little progress has been made in identifying new drug targets for the treatment of ileus. Inflammatory mediators play a critical role in the development of ileus, but surprisingly little is known about the direct effects of inflammatory mediators on cells of the gastrointestinal tract, and many of the studies are conflicting. Understanding the effects of inflammatory cytokines/chemokines on the development of ileus will facilitate the early identification of patients who will develop ileus and the identification of new drug targets to treat ileus. Thus, herein, we review the published literature concerning the effects of inflammatory mediators on gastrointestinal motility.

Electroacupuncture versus sham electroacupuncture in the treatment of postoperative ileus after laparoscopic surgery for colorectal cancer: study protocol for a multicentre, randomised, sham-controlled trial

INTRODUCTION

Postoperative ileus (POI) is an inevitable complication of almost all abdominal surgeries, which results in prolonged hospitalisation and increased healthcare costs. Various treatment strategies have been developed for POI but with limited success. Electroacupuncture (EA) might be a potential therapy for POI. However, evidence from rigorous trials that evaluated the effectiveness of EA for POI is limited. Thus, the aim of this study was to examine whether EA can safely reduce the time to the first defecation after laparoscopic surgery in patients with POI.

METHODS AND ANALYSIS

This multicentre randomised sham-controlled trial will be conducted in four hospitals in China. A total of 248 eligible participants with colorectal cancer who will undergo laparoscopic surgery will be randomly allocated to an EA group and a sham EA group in a 1:1 ratio. Treatment will be performed starting on postoperative day 1 and continued for four consecutive days, once per day. If the participant is discharged within 4 days after surgery, the treatment will cease on the day of discharge. The primary outcome will be the time to first defecation. The secondary outcome measures will include time to first flatus, tolerability of semiliquid and solid food, length of postoperative hospital stay, postoperative nausea and vomiting, abdominal distension, postoperative pain, postoperative analgesic, time to first ambulation, blinding assessment, credibility and expectancy and readmission rate.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of Beijing University of Chinese Medicine (number 2020BZHYLL0116) and the institutional review board of each hospital. The results will be disseminated through peer-reviewed publications. This study protocol (V.3.0, 6 March 2020) involves human participants and was approved by the ethics committees of Beijing University of Chinese Medicine (number 2020BZHYLL0116), Beijing Friendship Hospital Affiliated to Capital Medical University (number 2020-P2-069-01), Beijing Chao-Yang Hospital Affiliated to Capital Medical University (number 2020-3-11-2), National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College (number 20/163-2359), and the Affiliated Hospital of Qingdao University (number QYFYKYLL711311920). The participants gave informed consent to participate in the study before taking part.

TRIAL REGISTRATION NUMBER

ChiCTR2000038444.

The Effect of Hepatic Impairment on the Pharmacokinetics of Intravenously Administered Felcisetrag (TAK‐954)

Felcisetrag (formerly known as TAK‐954) is a selective serotonin receptor agonist under investigation for use in patients with postoperative gastrointestinal dysfunction. The safety, tolerability, and pharmacokinetics (PK) of intravenous (i.v.) felcisetrag have been studied, but little is known about the effect of hepatic impairment on the PK of the drug. This phase 1, non‐randomized, open‐label study compared the PK of a single 60‐minute i.v. infusion of felcisetrag between healthy individuals (n = 8) and patients with moderate (n = 10) or severe (n = 7) hepatic impairment. The primary study end points were the total and free maximum observed plasma concentration of felcisetrag at the end of infusion (C_max), area under the concentration–time curve (AUC) from time 0 to the time of the last quantifiable concentration (AUC_last), and AUC from time 0 to infinity (AUC_inf). Concentration–time profiles of felcisetrag were similarly shaped between groups but revealed lower concentrations of total plasma felcisetrag with increasing severity of hepatic impairment, whereas concentrations of free felcisetrag increased. The ratios of AUC_last and AUC_inf for patients with severe hepatic impairment were up to 29.3% lower for total felcisetrag and up to 29.2% higher for free felcisetrag than found in healthy individuals (P < .05). Infusions were well tolerated with no discontinuations, severe adverse events, or deaths during the study. Overall, the effect of hepatic impairment on exposure to felcisetrag was minimal, suggesting that dose adjustment may be unnecessary in patients with hepatic impairment.

Comparison of prolonged postoperative ileus between laparoscopic right and left colectomy under enhanced recovery after surgery: a propensity score matching analysis

Background

There were differences in the recovery of bowel function and prolonged postoperative ileus (PPOI) between laparoscopic right colectomy (RC) and left colectomy (LC) under the guidance of enhanced recovery after surgery.

Methods

We selected 870 patients who underwent elective laparoscopic colectomy from June 2016 to December 2021, including 272 patients who had RC and 598 who had LC. According to 1:1 proportion for propensity score matching and correlation analysis, 247 patients who had RC and 247 who had LC were finally enrolled.

Results

The incidence of PPOI in all patients was 13.1%. Age, sex, smoking habit, preoperative serum albumin level, operation type, and operation time were the important independent risk factors based on multivariate logistic regression and correlation analysis for PPOI (p<0.05). Age, sex, body mass index, preoperative serum albumin level, operation time, and degree of differentiation between the two groups were significantly different before case matching (p<0.05). There were no statistically significant differences in baseline characteristics and preoperative biochemical parameters between the two groups after case matching (p>0.05). The incidence of PPOI in patients who had RC was 21.9%, while that in patients who had LC was 13.0%. The first flatus, first semi-liquid, and length of stay in LC patients were lower than those in RC patients (p<0.05).

Conclusion

The return of bowel function in LC was faster than that in RC, and the incidence of PPOI was relatively lower. Therefore, caution should be taken during the early feeding of patients who had laparoscopic RC.

Data analytics and artificial intelligence in predicting length of stay, readmission, and mortality: a population-based study of surgical management of colorectal cancer

Data analytics and artificial intelligence (AI) have been used to predict patient outcomes after colorectal cancer surgery. A prospectively maintained colorectal cancer database was used, covering 4336 patients who underwent colorectal cancer surgery between 2003 and 2019. The 47 patient parameters included demographics, peri- and post-operative outcomes, surgical approaches, complications, and mortality. Data analytics were used to compare the importance of each variable and AI prediction models were built for length of stay (LOS), readmission, and mortality. Accuracies of at least 80% have been achieved. The significant predictors of LOS were age, ASA grade, operative time, presence or absence of a stoma, robotic or laparoscopic approach to surgery, and complications. The model with support vector regression (SVR) algorithms predicted the LOS with an accuracy of 83% and mean absolute error (MAE) of 9.69 days. The significant predictors of readmission were age, laparoscopic procedure, stoma performed, preoperative nodal (N) stage, operation time, operation mode, previous surgery type, LOS, and the specific procedure. A BI-LSTM model predicted readmission with 87.5% accuracy, 84% sensitivity, and 90% specificity. The significant predictors of mortality were age, ASA grade, BMI, the formation of a stoma, preoperative TNM staging, neoadjuvant chemotherapy, curative resection, and LOS. Classification predictive modelling predicted three different colorectal cancer mortality measures (overall mortality, and 31- and 91-days mortality) with 80-96% accuracy, 84-93% sensitivity, and 75-100% specificity. A model using all variables performed only slightly better than one that used just the most significant ones.

Self-administered succus entericus reinfusion before ileostomy closure improves short-term outcomes

OBJECTIVE

The study aims to assess whether reinfusion of succus entericus prior to ileostomy closure can decrease postoperative length of stay and ameliorate low anterior resection score.

METHODS

This study is a retrospective analysis based on prospectively collected data. Patients were screened from May 2016 to November 2019. A total of 30 patients who underwent reinfusion with succus entericus (SER) were enrolled in the SER group and 42 patients without SER were enrolled in the non-SER group.

RESULTS

There was no significant difference in the incidence of postoperative ileus between succus entericus reinfusion (SER) group and the control group. Time to first passage of flatus or stool after surgery in the SER group (27.9 ± 6.02 h) is significantly shorter than the control group (32.3 ± 6.26, hours p = 0.004). Compared with the control group (5.52 (4.0-7.0) days), postoperative length of stay in the SER group was 4.90 (3.0-7.0)days (p = 0.009). As for low anterior resection score(LARS), the SER group had a lower score 1 week after discharge than the control group (p = 0.034). However, 1 month after discharge, the LARS in the two groups had no significant difference.

CONCLUSIONS

Self-administered succus entericus reinfusion is a feasible prehabilitation management for outpatients and can improve better outcomes. Compared with non-reinfusion group, succus enterius reinfusion group displays significantly shorter time for gastrointestinal function recovery and postoperative hospital stay without increasing complication, and it can bring better quality of life in a short term.

Prolonged postoperative ileus following right- versus left-sided colectomy: A systematic review and meta-analysis

AIM

Prolonged postoperative ileus (PPOI) is a common complication following colonic surgery, and is associated with longer hospital stay, greater risk of complications and substantial cost for patients and hospitals. Some reports have recently suggested that gastrointestinal (GI) recovery varies based on the side of resection (i.e., right-sided vs. left-sided colectomy). This systematic review and meta-analysis aimed to compare GI recovery by resection side.

METHODS

The MEDLINE, Embase, Cochrane Library and CENTRAL databases were systematically searched for articles reporting GI recovery outcomes in adults undergoing elective right- versus left-sided colectomy (excluding with ileostomy) of any surgical approach. The primary outcome was PPOI, and secondary outcomes included time to first passage of flatus, stool and tolerance of solid diet, and postoperative complications. Subgroup analyses of laparoscopic procedures and cohorts without inflammatory bowel disease and sensitivity analysis of adjusted multivariate results were also performed.

RESULTS

Nine studies were identified, of which seven were included in the meta-analysis, comprising 29 068 colectomies (14 581 right-sided; 14 487 left-sided). PPOI was heterogeneously defined and was significantly more likely following right-sided compared to left-sided colectomy regardless of the surgical approach (OR 1.78, 95% CI 1.32-2.39; P < 0.01; I²  = 51%), as well as on subgroup analyses and adjusted multivariate meta-analysis. Secondary outcomes were reported in only a few small studies; hence meta-analysis did not produce reliable results.

CONCLUSION

Based on heterogeneous definitions, consistently higher rates of PPOI were observed following right- versus left-sided colectomy. These differences are currently unexplained and highlight the need for further research into the pathophysiology of ileus.

Improved motility in the gastrointestinal tract of a postoperative ileus rat model with ilaprazole

Postoperative ileus (POI), a symptom that occurs after abdominal surgery, reduces gastrointestinal motility. Although its mechanism is unclear, POI symptoms are known to be caused by inflammation 6 to 72 h after surgery. As proton pump inhibitors exhibit protective effect against acute inflammation, the purpose of this study was to determine the effect of ilaprazole on a POI rat model. POI was induced in rats by abdominal surgery. Rats were divided into six groups: control: normal rat + 0.5% CMC-Na, vehicle: POI rat + 0.5% CMC-Na, mosapride: POI rat + mosapride 2 mg/kg, ilaprazole 1 mg/kg: POI rat + ilaprazole 1 mg/kg, ilaprazole 3 mg/kg: POI rat + ilaprazole 3 mg/kg, and ilaprazole 10 mg/kg: POI rat + ilaprazole 10 mg/kg. Gastrointestinal motility was confirmed by measuring gastric emptying (GE) and gastrointestinal transit (GIT). In the small intestine, inflammation was confirmed by measuring TNF-α and IL-1β; oxidative stress was confirmed by SOD, GSH, and MDA levels; and histological changes were observed by H&E staining. Based on the findings, GE and GIT were decreased in the vehicle group and improved in the ilaprazole 10 mg/kg group. In the ilaprazole 10 mg/kg group, TNF-α and IL-1β levels were decreased, SOD and GSH levels were increased, and MDA levels were decreased. Histological damage was also reduced in the ilaprazole-treated groups. These findings suggest that ilaprazole prevents the decrease in gastrointestinal motility, a major symptom of postoperative ileus, and reduces inflammation and oxidative stress.

Post-operative ileus: definitions, mechanisms and controversies

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

Effect of Intraoperative Dexmedetomidine on Recovery of Gastrointestinal Function After Abdominal Surgery in Older Adults: A Randomized Clinical Trial

IMPORTANCE

Postoperative ileus is common after abdominal surgery, and small clinical studies have reported that intraoperative administration of dexmedetomidine may be associated with improvements in postoperative gastrointestinal function. However, findings have been inconsistent and study samples have been small. Further examination of the effects of intraoperative dexmedetomidine on postoperative gastrointestinal function is needed.

OBJECTIVE

To evaluate the effects of intraoperative intravenous dexmedetomidine vs placebo on postoperative gastrointestinal function among older patients undergoing abdominal surgery.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, double-blind, placebo-controlled randomized clinical trial was conducted at the First Affiliated Hospital of Anhui Medical University in Hefei, China (lead site), and 12 other tertiary hospitals in Anhui Province, China. A total of 808 participants aged 60 years or older who were scheduled to receive abdominal surgery with an expected surgical duration of 1 to 6 hours were enrolled. The study was conducted from August 21, 2018, to December 9, 2019.

INTERVENTIONS

Dexmedetomidine infusion (a loading dose of 0.5 μg/kg over 15 minutes followed by a maintenance dose of 0.2 μg/kg per hour) or placebo infusion (normal saline) during surgery.

MAIN OUTCOMES AND MEASURES

The primary outcome was time to first flatus. Secondary outcomes were postoperative gastrointestinal function measured by the I-FEED (intake, feeling nauseated, emesis, physical examination, and duration of symptoms) scoring system, time to first feces, time to first oral feeding, incidence of delirium, pain scores, sleep quality, postoperative nausea and vomiting, hospital costs, and hospital length of stay.

RESULTS

Among 808 patients enrolled, 404 were randomized to receive intraoperative dexmedetomidine, and 404 were randomized to receive placebo. In total, 133 patients (60 in the dexmedetomidine group and 73 in the placebo group) were excluded because of protocol deviations, and 675 patients (344 in the dexmedetomidine group and 331 in the placebo group; mean [SD] age, 70.2 [6.1] years; 445 men [65.9%]) were included in the per-protocol analysis. The dexmedetomidine group had a significantly shorter time to first flatus (median, 65 hours [IQR, 48-78 hours] vs 78 hours [62-93 hours], respectively; P < .001), time to first feces (median, 85 hours [IQR, 68-115 hours] vs 98 hours [IQR, 74-121 hours]; P = .001), and hospital length of stay (median, 13 days [IQR, 10-17 days] vs 15 days [IQR, 11-18 days]; P = .005) than the control group. Postoperative gastrointestinal function (as measured by the I-FEED score) and delirium incidence were similar in the dexmedetomidine and control groups (eg, 248 patients [72.1%] vs 254 patients [76.7%], respectively, had I-FEED scores indicating normal postoperative gastrointestinal function; 18 patients [5.2%] vs 12 patients [3.6%] had delirium on postoperative day 3).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, the administration of intraoperative dexmedetomidine reduced the time to first flatus, time to first feces, and length of stay after abdominal surgery. These results suggest that this therapy may be a viable strategy to enhance postoperative recovery of gastrointestinal function among older adults.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR1800017232.

Impact of intravenous dexmedetomidine on postoperative bowel movement recovery after laparoscopic nephrectomy: A consort-prospective, randomized, controlled trial

BACKGROUND

Postoperative ileus is a frequent postoperative complication, especially after abdominal surgery. Sympathetic excitation is the primary factor for postoperative ileus. Sympathetic activation becomes increased by surgical stress, postoperative pain, and inflammation. Dexmedetomidine (DEX) can inhibit sympathetic nerve activity, inflammation, and pain.

AIM

To observe whether DEX promotes bowel movements in patients after laparoscopic nephrectomy.

METHODS

One hundred and twenty patients undergoing laparoscopic nephrectomy were assigned to three groups: C (normal saline infusion), D1 (DEX 0.02 µg/kg/h), and D2 (DEX 0.04 µg/kg/h). The primary outcomes were the recorded times to first flatus, defecation, and eating after surgery. The secondary outcomes were postoperative pain, assessed using the numerical rating scale (NRS), adverse effects, and the duration of the postoperative hospital stay.

RESULTS

The times to first flatus, defecation, and eating in groups D1 and D2 were significantly shorter than those in group C (P < 0.01). The NRS scores at 8 h and 24 h after surgery were significantly lower in groups D1 and D2 than in group C (P < 0.05). No adverse effects were observed (P > 0.05).

CONCLUSION

Postoperative infusion of DEX at 0.04 µg/kg/h facilitates bowel movements in patients undergoing laparoscopic nephrectomy.

Determinación de los factores predictivos para complicaciones en cirugía electiva de pacientes con cáncer colorrectal. Experiencia del Instituto de Cancerología Las Américas Auna (Colombia, 2016-2019)

Introducción. El pilar fundamental del tratamiento del cáncer colorrectal es la cirugía, situación que expone a los pacientes a la posible presentación de complicaciones, morbimortalidad, pobre calidad de vida, recurrencia tumoral o la muerte. El objetivo de este estudio fue determinar las variables clínicas y quirúrgicas que inciden en el riesgo de la aparición de complicaciones en los pacientes con cáncer colorrectal llevados a cirugía electiva entre los años 2016 y 2019. Métodos. Estudio observacional, descriptivo, transversal y retrospectivo. Se incluyeron pacientes mayores de 18 años con cáncer colorrectal sometidos a cirugía electiva. Se realizó un análisis multivariado para determinar los factores que se relacionan con las complicaciones postquirúrgicas. Resultados. Se incluyeron 298 pacientes, 68 % mayores de 60 años, 52,3 % mujeres, 74,2 % presentaban comorbilidades y 48,3 % fueron diagnosticados en estadio III. El 48,3 % presentó complicaciones postoperatorias. De ellos, el 68,1 % no tenía tamización nutricional y el 61,8 % no tenía preparación del colon; un 55 % fueron cirugías del recto, 69,1 % de las cirugías fueron por vía laparoscópica y 71,8 % presentaron sangrado inferior a 500 ml. La mayoría de las complicaciones fueron clasificadas como Clavien-Dindo I-III. Discusión. Las características de los pacientes fueron similares a los presentados en otros estudios, aunque hubo mayor incidencia de íleo postoperatorio. El análisis multivariado mostró una mayor probabilidad de presentar una complicación en pacientes con diabetes mellitus, hipertensión arterial, falta de tamización nutricional o preparación de colon, cirugía de recto y el sangrado mayor a 500 ml.

Non-invasive, vagus nerve stimulation to reduce ileus after colorectal surgery: protocol for a feasibility trial with nested mechanistic studies

INTRODUCTION

Ileus is a common and distressing condition characterised by gut dysfunction after surgery. While a number of interventions have aimed to curtail its impact on patients and healthcare systems, ileus is still an unmet challenge. Electrical stimulation of the vagus nerve is a promising new treatment due to its role in modulating the neuro-immune axis through a novel anti-inflammatory reflex. The protocol for a feasibility study of non-invasive vagus nerve stimulation (nVNS), and a programme of mechanistic and qualitative studies, is described.

METHODS AND ANALYSIS

This is a participant-blinded, parallel-group, randomised, sham-controlled feasibility trial (IDEAL Stage 2b) of self-administered nVNS. One hundred forty patients planned for elective, minimally invasive, colorectal surgery will be randomised to four schedules of nVNS before and after surgery. Feasibility outcomes include assessments of recruitment and attrition, adequacy of blinding and compliance to the intervention. Clinical outcomes include bowel function and length of hospital stay. A series of mechanistic substudies exploring the impact of nVNS on inflammation and bowel motility will inform the design of the final stimulation schedule. Semistructured interviews with participants will explore experiences and perceptions of the intervention, while interviews with patients who decline participation will explore barriers to recruitment.

ETHICS AND DISSEMINATION

The protocol has been approved by the Tyne and Wear South National Health Service (NHS) Research Ethics Committee (19/NE/0217) on 2 July 2019. Feasibility, mechanistic and qualitative findings will be disseminated to national and international partners through peer-reviewed publications, academic conferences, social media channels and stakeholder engagement activities. The findings will build a case for or against progression to a definitive randomised assessment as well as informing key elements of study design.

TRIAL REGISTRATION NUMBER

ISRCTN62033341.

Male sex, ostomy, infection, and intravenous fluids are associated with increased risk of postoperative ileus in elective colorectal surgery

BACKGROUND

Postoperative ileus is a common and costly complication after elective colorectal surgery. Effects of intravenous fluid administration remain controversial, and the effect of ostomy construction has not been fully evaluated. Various restrictive intravenous fluid protocols may adversely affect renal function. We aimed to investigate the impact of intestinal reconstruction and intravenous fluid on ileus and renal function after colorectal resection under an enhanced recovery protocol.

METHODS

A retrospective study of a prospectively maintained institutional database for a tertiary academic medical center following National Surgical Quality Improvement Program standards was reviewed, analyzing elective colorectal resections performed under enhanced recovery protocol from 2015 to 2018. Postoperative ileus was defined as nasogastric decompression, nil per os >3 days postoperatively, or nasogastric tube insertion. Patients with and without ileus were compared. Intravenous fluid and different anastomoses and ostomies were investigated. Acute kidney injury was a secondary outcome, due to the potential of renal damage with restriction of intravenous fluid volume during and after surgery and controversy in current literature in this matter.

RESULTS

Postoperative ileus occurred in 18.5% of patients (n = 464). Male sex (odds ratio 1.97, 95% confidence interval 1.12-3.52) and postoperative infection (odds ratio 2.13, 95% confidence interval 1.03-4.35) were associated with ileus. Compared to colorectal anastomosis, ileostomy/ileorectal anastomosis had the highest risk of ileus (odds ratio 4.9, 95% confidence interval 2.33-11.3), colostomy second highest (odds ratio 3.3, 95% confidence interval 1.35-8.39), while ileocolic anastomosis did not significantly differ (odds ratio 2.06, 95% confidence interval 0.69-5.85) on multivariate analysis. Each liter of intravenous fluid within the first 72 hours significantly correlated with postoperative ileus (odds ratio 1.41, 95% confidence interval 1.27-1.59). Rates of acute kidney injury did not differ (P = .18).

CONCLUSION

Each additional liter of intravenous fluid given in the first 72 hours increased the risk of postoperative ileus 1.4-fold. There is substantially higher risk of ileus with male sex, infection, ileostomy/ileorectal anastomosis, and colostomy. Judicious use of intravenous fluid, as described in our enhanced recovery protocol, is not detrimental for renal function in the setting of normal baseline.