Perioperative Factors Predicting Prolonged Postoperative Ileus After Major Abdominal Surgery

Caffeine intake enhances bowel recovery after colorectal surgery: a meta-analysis of randomized and non-randomized studies

Postoperative ileus (POI) after colorectal surgery is a major problem that affects both patient recovery and hospital costs highlighting the importance of preventive strategies. Therefore, we aimed to perform a systematic analysis of the effects of postoperative caffeine consumption on bowel recovery and surgical morbidity after colorectal surgery. A comprehensive literature search was conducted through September 2023 for randomized and non-randomized trials comparing the effect of caffeinated versus non-caffeinated drinks on POI by evaluating bowel movement resumption, time to first flatus and solid food intake, and length of hospital stay (LOS). Secondary outcome analysis included postoperative morbidity in both groups. After data extraction and inclusion in a meta-analysis, odds ratios (ORs) for dichotomous variables and standardized mean differences (SMDs) for continuous outcomes with 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed in cases of substantial heterogeneity. Six randomized and two non-randomized trials with a total of 610 patients were included in the meta-analysis. Caffeine intake significantly reduced time to first bowel movement [SMD -0.39, (95% CI -0.66 to -0.12), p = 0.005] and time to first solid food intake [SMD -0.41, (95% CI -0.79 to -0.04), p = 0.03] in elective laparoscopic colorectal surgery, while time to first flatus, LOS, and the secondary outcomes did not differ significantly. Postoperative caffeine consumption may be a reasonable strategy to prevent POI after elective colorectal surgery. However, larger randomized controlled trials (RCTs) with homogeneous study protocols, especially regarding the dosage form of caffeine and coffee, are needed.

Prognostic factors associated with gastrointestinal dysfunction after gastrointestinal tumor surgery: A meta-analysis

BACKGROUND

Explore the risk factors of gastrointestinal dysfunction after gastrointestinal tumor surgery and to provide evidence for the prevention and intervention of gastrointestinal dysfunction in patients with gastrointestinal tumor surgery.

AIM

To investigate the potential risk factors for gastrointestinal dysfunction following gastrointestinal tumor surgery and to present information supporting the prevention and management of gastrointestinal dysfunction in surgery patients.

METHODS

Systematically searched the relevant literature from PubMed, Web of Science, Cochrane Library, Embase, CNKI, China Biomedical Database, Wanfang Database, and Weipu Chinese Journal Database self-established until October 1, 2022. Review Manager 5.3 software was used for meta-analysis after two researchers independently screened literature, extracted data, and evaluated the risk of bias in the included studies.

RESULTS

A total of 23 pieces of literature were included, the quality of which was medium or above, and the total sample size was 43878. The results of meta-analysis showed that the patients were male (OR = 1.58, 95%CI: 1.25-2.01, P = 0.002) and ≥ 60 years old (OR = 2.60, 95%CI: 1.76-2.87, P < 0.001), physical index ≥ 25.3 kg/m2 (OR = 1.6, 95%CI: 1.00-1. 12, P = 0.040), smoking history (OR = 1.89, 95%CI: 1.31-2.73, P < 0.001), chronic obstructive pulmonary disease (OR = 1.49, 95%CI: 1.22-1.83, P < 0.001), enterostomy (OR = 1.47, 95%CI: 1.26-1.70, P < 0.001), history of abdominal surgery (OR = 2.90, 95%CI: 1.67-5.03, P < 0.001), surgical site (OR = 1.2, 95%CI: 1.40-2.62, P < 0.001), operation method (OR = 1.68, 95%CI: 1.08-2.62, P = 0.020), operation duration (OR = 2.65, 95%CI: 1.92-3.67, P < 0.001), abdominal adhesion grade (OR = 2.52, 95%CI: 1.90-3.56, P < 0.001), postoperative opioid history (OR = 5.35, 95%CI: 3.29-8.71, P < 0.001), tumor TNM staging (OR = 2.58, 95%CI: 1.84-3.62, P < 0.001), postoperative blood transfusion (OR = 2.92, 95%CI: 0.88-9.73, P = 0.010) is a risk factor for postoperative gastrointestinal dysfunction in patients with gastrointestinal tumors.

CONCLUSION

There are many factors affecting gastrointestinal dysfunction in gastrointestinal patients after surgery. Clinical staff should identify relevant risk factors early and implement targeted intervention measures on the basis of personalized assessment to improve the clinical prognosis of patients.

Abdominal massage to prevent ileus after colorectal surgery. A single-center, prospective, randomized clinical trial: the MATRAC Trial

BACKGROUND

There is scarce literature on the effect of mechanical abdominal massage on the duration of ileus after colectomy, particularly in the era of enhanced recovery after surgery (ERAS). The aim of this study was to determine whether abdominal massage after colorectal surgery with anastomosis and no stoma helps toward a faster return of intestinal transit.

METHODS

This study was a superiority trial and designed as a prospective open-label, single-center, randomized controlled clinical trial with two parallel groups. Patients scheduled to undergo intestinal resection and follow an ERAS protocol were randomly assigned to either the standard ERAS group or the ERAS plus massage group. The primary endpoint was the return of intestinal transit, defined as the first passage of flatus following the operation. Secondary endpoints included time of the first bowel motion, maximal pain, 30 day complications, complications due to massage, anxiety score given by the Hospital Anxiety and Depression (HAD) questionnaire, and quality of life assessed by the EQ-5D-3L questionnaire.

RESULTS

Between July 2020 and June 2021, 36 patients were randomly assigned to the ERAS group or the ERAS plus massage group (n = 19). Patients characteristics were comparable. There was no significant difference in time to passage of the first flatus between the ERAS group and the ERAS plus abdominal massage group (1065 versus 1389 min, p = 0.274). No statistically significant intergroup difference was noted for the secondary endpoints.

CONCLUSION

Our study, despite its limitations, failed to demonstrate any advantage of abdominal massage to prevent or even reduce symptoms of postoperative ileus after colorectal surgery.

TRIAL REGISTRATION NUMBER

38RC20.021.

Early Diet Liberalization After Anterior Lumbar Interbody Fusion Improves Postoperative Recovery

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

The objective of this study was to assess the impact of diet liberalization on short-term outcomes in patients undergoing anterior interbody lumbar fusion (ALIF).

METHODS

A retrospective review was performed for patients undergoing ALIF at our tertiary care center institution from 2010 to 2022. Electronic medical records were reviewed for demographics, surgical characteristics, and 90-day postoperative outcomes.

RESULTS

We included 515 patients in this study with 102 patients receiving a full diet on the same day as their operation. All other patients had a delay of at least 1 day (average 1.6 days) until a full diet was provided. This group was found to have a higher rate of postoperative ileus (10.2% vs 2.9%) and urinary retention (16.0% vs 3.9%). The readmission rate and percent of patients presenting to the emergency department within 90 days postoperatively were similar. On multivariate regression analysis, same-day, full-diet patients had decreased odds of developing urinary retention (OR = .17) and a shorter length of hospital stay (Estimate: -.99). Immediate full diet had no impact on the development of ileus (OR: .33).

CONCLUSIONS

An immediate postoperative full diet following an anterior approach to the lumbar spine was not found to be associated with an increased risk of postoperative ileus in patients deemed appropriate for early diet liberalization. Moreover, an early full diet was found to reduce length of hospitalization and risk of postoperative urinary retention. Reconsideration of postoperative diet protocols may help optimize patient outcomes and recovery.

Nomogram for predicting prolonged postoperative ileus after laparoscopic low anterior resection for rectal cancer

BACKGROUND

Prolonged postoperative ileus (PPOI) is a common complication after colorectal surgery that increases patient discomfort, hospital stay, and financial burden. However, predictive tools to assess the risk of PPOI in patients undergoing laparoscopic low anterior resection have not been developed. Thus, the purpose of this study was to develop a nomogram to predict PPOI after laparoscopic low anterior resection for rectal cancer.

METHODS

A total of 548 consecutive patients who underwent laparoscopic low anterior resection for mid-low rectal cancer at a single tertiary medical center were retrospectively enrolled between January 2019 and January 2023. Univariate and multivariate logistic regression analysis was performed to analyze potential predictors of PPOI. The nomogram was constructed using the filtered variables and internally verified by bootstrap resampling. Model performance was evaluated by receiver operating characteristic curve and calibration curve, and the clinical usefulness was evaluated by the decision curve.

RESULTS

Among 548 consecutive patients, 72 patients (13.1%) presented with PPOI. Multivariate logistic analysis showed that advantage age, hypoalbuminemia, high surgical difficulty, and postoperative use of opioid analgesic were independent prognostic factors for PPOI. These variables were used to construct the nomogram model to predict PPOI. Internal validation, conducted through bootstrap resampling, confirmed the great discrimination of the nomogram with an area under the curve of 0.738 (95%CI 0.736-0.741).

CONCLUSIONS

We created a novel nomogram for predicting PPOI after laparoscopic low anterior resection. This nomogram can assist surgeons in identifying patients at a heightened risk of PPOI.

Nomogram for predicting prolonged postoperative ileus in colorectal cancer based on age and inflammatory markers

Aim: To explore the relationship between inflammatory markers and prolonged postoperative ileus (PPOI), and to establish a nomogram for predicting PPOI. Patients & methods: The data of 229 patients were analyzed retrospectively. Univariate and multivariate logistic regression analysis were used to analyze the risk factors affecting the occurrence of PPOI. The predictive model of PPOI was established and verified internally. Results: Postoperative PPOI occurred in 87 (38.0%) of all 229 patients. Our study showed that age, preoperative neutrophil-lymphocyte ratio and changes in neutrophil-lymphocyte ratio were independent risk factors for PPOI. Conclusion: The nomograms established based on these independent risk factors have good predictive efficacy and may be able to guide clinicians to individualize the diagnosis and treatment.

A clinical nomogram for predicting small bowel obstruction after extubation after radical resection of esophageal cancer and jejunostomy

BACKGROUND

Small bowel obstruction after extubation is among the most serious complications of radical esophageal cancer and jejunostomy resection. This study aimed to explore the risk factors and treatment methods for small bowel obstruction after extubation and construct a predictive model to guide its clinical management.

METHODS

Clinical data for 514 patients who underwent esophagectomy with jejunostomy for esophageal cancer were collected. A nomogram was constructed using the independent risk factors for small bowel obstruction after extubation determined on multivariable logistic regression analysis, and a subgroup analysis was performed of the treatment methods for the 61 patients with small bowel obstruction after extubation.

RESULTS

The nomogram incorporated the independent risk factors for small bowel obstruction after extubation (gastrointestinal function recovery [P < .001], postoperative albumin reduction ratio [P = .009], and serious postoperative complications [P < .001]) in the multivariable logistic regression analysis. The final model had an area under the curve of 0.829 (95% confidence interval, 0.775-0.883). The calibration plots demonstrated high concordance between the predicted and actual probabilities. The model demonstrated excellent discriminatory power for internal and time validation, with adjusted C-statistics of 0.821 and 0.810 (95% confidence interval, 0.686-0.933), respectively. In the subgroup analysis, an abnormal anion gap (P = .016) and low serum albumin level (P = .005) were associated with recurrent small bowel obstruction. The model's area under the curve was 0.815 (95% confidence interval, 0.683-0.948). The probability of recurrence among patients with small bowel obstruction after extubation was 78.3% when the 2 risk factors were present.

CONCLUSION

The clinical nomogram based on small bowel obstruction after extubation predictors recommends aggressive surgical intervention for patients with small bowel obstruction after extubation and an abnormal anion gap and low serum albumin level at admission.

Effect of Chewing Gum on Duration of Postoperative Ileus Following Laparotomy for Gastroduodenal Perforations: Protocol for a Randomized Controlled Trial

Background

Prolonged post-operative ileus is associated with increased risk of other complications, length of hospital stays and health care related costs. Chewing gum has been shown to reduce duration of ileus in many elective surgeries, but there is a paucity of randomised controlled trials (RCTs) on its effect on duration of ileus among patients undergoing emergency surgery, specifically patients with peritonitis. The aim of this study is to determine the effect of chewing gum on duration of postoperative ileus following laparotomy for gastroduodenal perforations.

Methods

This will be a randomised controlled trial done in 3 hospitals. Fifty-two patients will be randomised to 2 groups. Group A will receive chewing gum in addition to routine care, whereas group B will receive routine care only. The duration of post-operative ileus in the two groups which is the primary outcome, will be compared using the independent samples t-test in SPSS version 22. The length of hospital stay, in-hospital morbidity and mortality will be the secondary outcomes. This trial has been approved by Kampala International University research and Ethics committee (Ref No. KIU-2021-60) and Uganda national council of science and technology (Ref No. HS1665ES). Retrospective registration with the research registry has also been done (UIN: researchregistry8565).

Highlights

Prolonged post-operative ileus significantly contributes to adverse surgical outcomesChewing gum has been shown to reduce duration of ileus in many elective surgeriesThere is paucity of RCTs on role of chewing gum following surgery for peritonitis.

Framework, component, and implementation of enhanced recovery pathways

The introduction of enhanced recovery pathways (ERPs) has led to a considerable paradigm shift towards evidence-based, multidisciplinary perioperative care. Such pathways are now widely implemented in a variety of surgical specialties, with largely positive results. In this narrative review, we summarize the principles, components and implementation of ERPs, focusing on recent developments in the field. We also discuss ‘special cases’ in ERPs, including: surgery in frail patients; emergency procedures; and patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2/COVID-19).

Predicting perioperative outcomes of robot-assisted radical cystectomy: Data from the Asian Robot-Assisted Radical Cystectomy Consortium

OBJECTIVES

To report the perioperative outcomes of robot-assisted radical cystectomy and elucidate their risk factors.

METHODS

A review of the Asian Robot-Assisted Radical Cystectomy Consortium database from 2007 to 2020 was performed. The perioperative outcomes studied included complication rates, time to solid food intake, estimated blood loss, length of hospital stay, and 30-day readmission rates.

RESULTS

Of 568 patients, the overall complication rate was 49.2%, comprising major complications in 15.6%. Preoperative hydronephrosis was associated with an increased risk of major complications (odds ratio 3.27, 95% confidence interval 1.48-7.26, P = 0.004) while neoadjuvant chemotherapy was protective (odds ratio 0.46, 95% confidence interval 0.25-0.84, P = 0.012). The median time to solid food intake was 4 days (interquartile range 3-7) and smoking was a risk factor (odds ratio 4.28, 95% confidence interval 2.36-7.79, P < 0.001) for prolonged time to solid food intake. Median length of hospital stay was 13 days (interquartile range 9-19), and diabetes mellitus (odds ratio 1.66, 95% confidence interval 1.08-2.56, P = 0.021), neoadjuvant chemotherapy (odds ratio 2.21, 95% confidence interval 1.46-3.33, P < 0.001), and orthotopic bladder substitute creation (odds ratio 2.82, 95% confidence interval 1.90-4.18, P < 0.001) were independent risk factors for prolonged length of hospital stay. The 30-day readmission rate was 23.4% and higher in those with bilateral hydronephrosis (odds ratio 4.58, 95% confidence interval 1.97-10.65, P < 0.001) and orthotopic bladder substitute creation (odds ratio 1.87, 95% confidence interval 1.16-3.02, P = 0.010).

CONCLUSIONS

There are preoperative conditions which are significant risk factors for adverse perioperative outcomes in robot-assisted radical cystectomy. Most are potentially modifiable and can direct strategies to reduce surgical morbidity related to this major oncological procedure.

A snapshot of intraoperative conditions to predict prolonged postoperative ileus after colorectal surgery

BACKGROUND

The cause of prolonged postoperative ileus (PPOI) is multifactorial. The influence of preoperative factors on PPOI has been well documented, but little is known about the impact of intraoperative conditions. The aim of this study was to investigate the influence of intraoperative factors on PPOI in patients undergoing colorectal surgery.

METHODS

The LekCheck study database of the Colorectal Unit at the Royal Adelaide Hospital was analysed. Per patient, over 60 data points were prospectively collected between March 2018 and July 2020. Intraoperative data were collected in theatre during a one-off snapshot measure. Univariate and multivariable logistic regression analyses were performed.

RESULTS

Data of 336 patients were included. The median age was 66 years and 58.3% were male. Ninety-three patients (27.7%) developed PPOI. Univariate analysis identified the following intraoperative variables as risk-factors of PPOI: greater volumes of intraoperative IV fluid administration (464 versus 415 mL/h for those without PPOI; p = 0.04), side-to-side anastomosis orientation (53.8 versus 41.2%; p = 0.04) and increased perioperative opioid use (6.73 versus 4.11 mg/kg morphine equivalents for patients with and without PPOI, respectively; p = 0.02). Upon multivariable analysis, increased perioperative opioid use remained significant (p = 0.05), as well as the preoperative factors anticoagulation use (p = 0.04) and higher levels of serum total protein (p = 0.02).

CONCLUSION

This study suggests that intraoperative factors may also contribute to the development of PPOI, but this could not be confirmed in the multivariate analysis. Further studies including larger patient numbers will be required to determine the impact of intraoperative conditions on the development of PPOI.

A nomogram to predict prolonged postoperative ileus after intestinal resection for Crohn's disease

PURPOSE

We aim to identify the risk factors of PPOI in patients with CD and create a nomogram for prediction of PPOI for CD.

METHODS

Data on 462 patients who underwent partial intestinal resection for CD in Jin-ling Hospital between January 2019 and June 2021 were retrospectively collected. Univariate and multivariate analyses were performed to determine the risk factors for PPOI and we used the risk factors to create a nomogram. Then we used the Bootstrap-Concordance index and calibration diagrams to evaluate the performance of the Nomogram. Decision curve analysis was performed to evaluate clinical practicability of the model.

RESULTS

The incidence of PPOI was 27.7% (n of N). Course of CD ≥ 10 years, operation time ≥ 154 min, the lowest mean arterial pressure ≤ 76.2 mmHg, in-out balance per body weight ≥ 22.90 ml/kg, post-op day 1 infusion ≥ 2847 ml, post-op lowest K⁺  ≤ 3.75 mmol/L, and post-op day 1 procalcitonin ≥ 2.445 ng/ml were identified as the independent risk factors of PPOI in patients with CD. The nomogram we created by these risk factors presented with good discriminative ability (concordance index 0.723) and was moderately calibrated (bootstrapped concordance index 0.704). The results of decision curve analysis showed that the nomogram was clinically effective within probability thresholds in the 8 to 66% range.

CONCLUSION

The nomogram we developed is helpful to evaluate the risk of developing PPOI after partial intestinal resection for CD. Clinicians can take more necessary measures to prevent PPOI in CD's patients or at least minimize the incidence.

Massage for gastrointestinal function among participants after abdominal surgery: A protocol for systematic review and meta-analysis

BACKGROUND

Postoperative gastrointestinal dysfunction (PGD) is one of the most common complications among participants undergoing abdominal surgery, with an incidence of 10%-30%. In China, massage is generally the most widely used technique to treat various diseases by the theory of Yin and Yang. In this study, our aim is to assess the effect and safety of massage on gastrointestinal function among participants undergoing abdominal surgery.

METHODS

We will search seven databases including Cochrane Library, MEDLINE, EMBASE, CNKI, VIP, CBM and WANGFANG. Meanwhile, we will include all randomized controlled trials if they recruited participants undergoing abdominal surgery. Primary outcomes will be the time to first defecation. Two authors will independently scan all the potential articles, extract the data and assess the risk of bias by Cochrane tool of risk of bias. Al analysis will be performed by RevMan 5.3 software. Dichotomous variables will be expressed as RR with 95% CIs and continuous variables will be reported as MD with 95% CIs. If possible, a fixed or random effects models will be conducted and the confidence of cumulative evidence will be assess using GRADE.

RESULTS

This study will be to assess the effect and safety of massage on gastrointestinal function among participants undergoing abdominal surgery.

CONCLUSIONS

This study will assess the effect and safety of massage among participants undergoing abdominal and move forward to help inform clinical decisions.

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.

Efficacy of Pelvic Peritoneum Closure After Laparoscopic Extralevator Abdominoperineal Excision for Rectal Cancer

BACKGROUND

The descent of the small bowel into the pelvic dead space after extralevator abdominoperineal excision (ELAPE) presents a higher risk for postoperative complications. The aim of the present study was to evaluate the efficacy of pelvic peritoneum closure in preventing the small bowel from descending into the pelvic dead space and the potential consequences of this approach.

METHODS

Patients with rectal cancer undergoing laparoscopic ELAPE from March 2014 to January 2019 were retrospectively investigated. Closure of the pelvic peritoneum (CPP) was routinely performed unless it was not feasible. All patients with pelvic peritoneum reconstruction were included in the CPP group, and patients without pelvic peritoneum reconstruction were included in the no-CPP group. The main outcomes included the incidences of the small bowel descending into the retro-urogenital space (space between the bladder/uterus and the sacrum on axial CT scans), perineal wound complications, perineal hernia, and small bowel obstruction (SBO).

RESULTS

Of the 100 patients included, 79 received CPP, and 21 did not. Fewer patients with pelvic peritoneum closure had small bowels residing in the retro-urogenital space than patients without closure (17.7% vs 42.9%, p=0.014). The incidence of SBO was also lower in the CPP group (7.6% vs. 23.8%, p=0.034). Multivariable analysis showed that no-CPP (p=0.014) was an independent risk factor for the small bowel descending into the retro-urogenital space.

CONCLUSION

CPP may prevent the small bowel from descending into the retro-urogenital dead space in patients undergoing laparoscopic ELAPE without increasing the incidence of perineal wound complications. Prospective studies are warranted to confirm the efficacy of CPP in preventing SBO and perineal hernia.

Preoperative physical activity and functional performance levels are predictors of acute postoperative outcomes in a private South African colorectal cancer cohort

BACKGROUND

For patients with colorectal cancer, surgical resection of the primary tumour remains the best treatment option. Surgery for colorectal cancer is being performed on patients who would previously not have been considered as suitable candidates. It remains to be seen which factors influence hospital length of stay (LOS) and the development of acute postoperative complications in South African patients.

OBJECTIVES

The objectives of our study were to determine the modifiable factors that influence patients' development of postoperative complications and hospital LOS and, to identify the types of postoperative complications that develop.

METHOD

A retrospective review and secondary analysis of information in an existing database of patients with colorectal cancer were conducted. Regression analysis statistics were used to determine the predictors of postoperative outcomes. The level of significance at which testing was performed was set at 5% (p ≤ 0.05).

RESULTS

Data of 125 patients were included. Surgical site infections and postoperative paralytic ileus were the most frequently reported postoperative complications. Preoperative vigorous-intensity physical activity (p = 0.048, β = -0.000) and functional performance status (p = 0.05, β = 0.926) significantly predicted hospital LOS and the incidence of postoperative complications, respectively.

CONCLUSION

Preoperative physical activity and functional performance levels are predictors of acute postoperative outcomes in a private South African cohort of patients with colorectal cancer. Future research which includes other modifiable factors is required to make informed suggestions for changes in clinical practice.

CLINICAL IMPLICATIONS

Patients requiring surgery for colorectal cancer should be screened for signs of physical deconditioning and referred for physiotherapy intervention before elective surgery to optimise their recovery.

Effect of sugammadex on the recovery of gastrointestional motility after open pancreaticoduodenectomy: a single-center retrospective study

BACKGROUND

This study aimed to investigate the association between sugammadex use and the occurrence of delayed passage of first flatus and oral intake tolerance following open pancreaticoduodenectomy (PD).

METHODS

We reviewed consecutive patients who underwent open PD between 2015 and 2019; subsequently, they were divided into the sugammadex (group S) and neostigmine with anticholinergics (group N) groups based on the reversal agent used. We performed stabilized inverse probability of treatment weighting (IPTW) analysis to adjust for baseline differences between the groups. We compared the delayed passage of first flatus, oral intake tolerance, and other postoperative outcomes between the groups before and after IPTW.

RESULTS

Of the 736 included patients, 309 (42.0%) received sugammadex. Stabilized IPTW revealed a significantly lower occurrence of delayed passage of first flatus in group S (19.5%) compared to group N (27.7%) (OR 0.61, 95% CI: 0.43-0.86, P = 0.005). Further, there was a significantly lower occurrence of delayed oral intake tolerance in group S (18.9%) than in group N (28.0%) (OR 0.65, 95% CI: 0.46-0.92, P = 0.016).

CONCLUSIONS

Compared to previous reversal agents, sugammadex use was significantly associated with a decrease in the occurrence of prolonged time to first flatus and oral intake tolerance following open PD.

Targets for Intervention? Preoperative Predictors of Postoperative Ileus After Colorectal Surgery in an Enhanced Recovery Protocol

BACKGROUND

Postoperative ileus occurs in up to 30% of colorectal surgery patients and is associated with increased length of stay, costs, and morbidity. While Enhanced Recovery Protocols seek to accelerate postoperative recovery, data on modifiable preoperative factors associated with postoperative ileus in this setting are limited. We aimed to identify preoperative predictors of postoperative ileus following colorectal surgery in Enhanced Recovery Protocols, to determine new intervention targets.

METHODS

We performed a retrospective single-center cohort study of patients ≥ 18 years old who underwent colorectal surgery via Enhanced Recovery Protocols (7/2015-7/2017). Postoperative ileus was defined as nasogastric tube insertion postoperatively or nil-per-os by postoperative day 4. Preoperative risk factors including comorbidities and medication use were identified using multivariable stepwise logistic regression.

RESULTS

Of 530 patients, 14.9% developed postoperative ileus. On univariate analysis of perioperative and postoperative factors, postoperative ileus patients had increased psychiatric illness, antidepressant and antipsychotic use, American Society of Anesthesiologists classification, ileostomy creation, postoperative opioid use, complications, surgery duration, and length of stay (p < 0.05). Multivariable logistic regression model for preoperative factors identified psychiatric illness, preoperative antipsychotic use, and American Society of Anesthesiologists classification ≥ 3 as significant predictors of postoperative ileus (p < 0.05).

DISCUSSION

Postoperative ileus remains a common complication following colorectal surgery under Enhanced Recovery Protocols. Patients with pre-existing psychiatric comorbidities and preoperative antipsychotic use may be a previously overlooked cohort at increased risk for postoperative ileus. Additional research and preoperative interventions within Enhanced Recovery Protocols to reduce postoperative ileus for this higher-risk population are needed.

Men and Those With a History of Smoking Are Associated With the Development of Postoperative Ileus Following Elective Colorectal Cancer Resection at a Private Academic Hospital in Johannesburg, South Africa: A Retrospective Cohort Study

Introduction: A scarcity of local published data on colorectal cancer (CRC) postoperative complications, including postoperative ileus (POI), exists. POI is a temporary gastrointestinal (GI) state of absent or reduced gastric motility shown to increase patient morbidity, prolong length-of-stay (LOS), and intensify the healthcare resource burden. The pathogenesis of POI involves a neurogenic and inflammatory phase plus a pharmacological component. Aim and Objectives: This study aimed to determine centre-specific preoperative risk factors associated with the development of ileus post elective therapeutic CRC resection. The objectives were to determine whether patient demographics; functional status; comorbidities; GI history; pharmacotherapy (including neoadjuvant chemotherapy); and lastly neoadjuvant radiation and chemoradiation were associated with the development of POI. Method: Patients who underwent CRC resection between January 2016 and May 2019 were retrospectively identified from an existing database. Urgent-or non-therapeutic surgeries; surgeries with the complication anastomotic leak or GI obstruction; patients under 18 at the time of surgery or surgeries preceded by preoperative parenteral nutrition were excluded. A comparison was done of the incidence of exposure in the study cohort to investigated variables as potential risk factors for the complication POI. Results: A total of 155 patient cases were included, and 56 (36%) of them developed POI. Univariate comparison of patients who developed POI with demographic characteristics of patients who did not suggested that women were at lower risk to develop POI compared to men (p = 0,013; RR 0,56; 95% CI 0,36-0,89). Functional status suggested that all previous smokers were at a higher risk to develop POI compared to lifetime non-smokers (p = 0,0069; RR 1,78; 95% CI 1,17-2,70). Multivariable comparison of ≤ 5 qualifying parameters showed no significance. Conclusion: The high local incidence of POI in this patient population shows that intervention is required to reduce the POI rate and improve postoperative outcomes. This study suggests that for men and all patients with a history of smoking both, CRC resection preoperative recommendations with the intention to prevent POI should include instructions initiating the activation of preventive strategies like the Enhanced Recovery After Surgery (ERAS) programme. More studies are needed to adequately determine local perioperative risk factors for POI.

Postoperative Ileus after Stimulation with Probiotics before Ileostomy Closure

Loop ileostomy closure after colorectal surgery is often associated with Postoperative ileus, with an incidence between 13-20%. The aim of this study is to evaluate the efficacy and safety of preoperative stimulation of the efferent loop with probiotics prior to ileostomy closure in patients operated on for colorectal carcinoma. For this, a prospective, randomized, double-blind, controlled study is designed. All patients who underwent surgery for colorectal carcinoma with loop ileostomy were included. Randomized and divided into two groups, 34 cases and 35 controls were included in the study. Postoperative ileus, the need for nasogastric tube insertion, the time required to begin tolerating a diet, restoration of bowel function, and duration of hospital stay were evaluated. The incidence of Postoperative ileus was similar in both groups, 9/34 patients stimulated with probiotics and 10/35 in the control group (CG) with a p = 0.192. The comparative analysis showed a direct relationship between Postoperative ileus after oncological surgery and Postoperative ileus after reconstruction surgery, independently of stimulation. Postoperative ileus after closure ileostomy is independent of stimulation of the ileostomy with probiotics through the efferent loop. There seem to be a relationship between Postoperative ileus after reconstruction and the previous existence of Postoperative ileus after colorectal cancer surgery.

Subtotal colectomy, extended right hemicolectomy, left hemicolectomy, or splenic flexure colectomy for splenic flexure tumors: a network meta-analysis

AIM

To perform a network meta-analysis of the current literature to evaluate the short-term and long-term outcomes of four operations for splenic flexure tumors.

METHODS

An electronic literature search of PubMed, Baidu Scholar, EMBASE, and Cochrane Central Register of Controlled Trials databases was performed up to August 2020. A Bayesian network meta-analysis was utilized to compare the outcomes involved in subtotal colectomy (STC), extended right hemicolectomy (ERHC), standard left hemicolectomy (LHC), and splenic flexure colectomy (SFC) by using R software.

RESULTS

A total of 10 non-randomized studies were included in this meta-analysis. There was no statistically significant difference among these 4 surgical techniques in terms of the utilization rate of minimally invasive surgery, reoperative surgery, anastomotic dehiscence, mortality, the proportion of patients with the number of lymph nodes harvested ≥ 12, local recurrence, distant recurrence and overall survival. Although ERHC was associated with a higher risk of postoperative ileus (ERHC vs SFC, OR = 6.4, 95% CI 1.4-45.0, P = 0.019), it has an advantage of a higher rate of primary anastomosis (ERHC vs LHC, OR = 4.2, 95% CI 1.3-18.0, P = 0.019) and a non-significant trend for lower anastomotic dehiscence when compared with more restrict resections.

CONCLUSION

SFC, LHC, ERHC and STC for the curative resection of splenic flexure tumors provide similar survival. An individualized surgical plan considering both long-term and short-term outcomes is necessary to select the appropriate operations.

Preoperative albumin levels predict prolonged postoperative ileus in gastrointestinal surgery

BACKGROUND

Prolonged postoperative ileus (PPOI) is a prolonged state of “pathological” gastrointestinal (GI) tract dysmotility. There are relatively few studies examining the influence of preoperative nutritional status on the development of PPOI in patients who underwent GI surgery. The association between preoperative albumin and PPOI has not been fully studied. We hypothesized that preoperative albumin may be an independent indicator of PPOI.

AIM

To analyze the role of preoperative albumin in predicting PPOI and to establish a nomogram for clinical risk evaluation.

METHODS

Patients were drawn from a prospective hospital registry database of GI surgery. A total of 311 patients diagnosed with gastric or colorectal cancer between June 2016 and March 2017 were included. Potential predictors of PPOI were analyzed by univariate and multivariable logistic regression analyses, and a nomogram for quantifying the presence of PPOI was developed and internally validated.

RESULTS

The overall PPOI rate was 21.54%. Advanced tumor stage and postoperative opioid analgesic administration were associated with PPOI. Preoperative albumin was an independent predictor of PPOI, and an optimal cutoff value of 39.15 was statistically calculated. After adjusting multiple variables, per unit or per SD increase in albumin resulted in a significant decrease in the incidence of PPOI of 8% (OR = 0.92, 95%CI: 0.85-1.00, P = 0.046) or 27% (OR = 0.73, 95%CI: 0.54-0.99, P = 0.046), respectively. Patients with a high level of preoperative albumin (≥ 39.15) tended to experience PPOI compared to those with low levels (< 39.15) (OR = 0.43, 95%CI: 0.24-0.78, P = 0.006). A nomogram for predicting PPOI was developed [area under the curve (AUC) = 0.741] and internally validated by bootstrap resampling (AUC = 0.725, 95%CI: 0.663-0.799).

CONCLUSION

Preoperative albumin is an independent predictive factor of PPOI in patients who underwent GI surgery. The nomogram provided a model to screen for early indications in the clinical setting.

A systematic review and meta-analysis of baseline risk factors for the development of postoperative ileus in patients undergoing gastrointestinal surgery

INTRODUCTION

Postoperative ileus occurs frequently following abdominal surgery. Identification of groups at high risk of developing ileus before surgery may allow targeted interventions. This review aimed to identify baseline risk factors for ileus.

METHODS

A systematic review was conducted with reference to PRISMA and MOOSE guidelines. It was registered on PROSPERO (CRD42017068697). Searches of MEDLINE, EMBASE and CENTRAL were undertaken. Studies reporting baseline risk factors for the development of postoperative ileus based on cohort or trial data and published in English were eligible for inclusion. Dual screening of abstracts and full texts was undertaken. Independent dual extraction was performed. Bias assessment was undertaken using the quality in prognostic studies tool. Meta-analysis using a random effects model was undertaken where two or more studies assessed the same variable.

FINDINGS

Searches identified 2,430 papers, of which 28 were included in qualitative analysis and 12 in quantitative analysis. Definitions and incidence of ileus varied between studies. No consistent significant effect was found for association between prior abdominal surgery, age, body mass index, medical comorbidities or smoking status. Male sex was associated with ileus on meta-analysis (odds ratio 1.12, 95% confidence interval 1.02-1.23), although this may reflect unmeasured factors. The literature shows inconsistent effects of baseline factors on the development of postoperative ileus. A large cohort study using consistent definitions of ileus and factors should be undertaken.

Are right-sided colectomies for neoplastic disease at increased risk of primary postoperative ileus compared to left-sided colectomies? A coarsened exact matched analysis

INTRODUCTION

The objective of this study was to determine whether right-sided colectomies (RC) were associated with a higher incidence of primary postoperative ileus (pPOI) compared to left-sided colectomies (LC).

METHODS

Patients who underwent elective colectomy for neoplastic disease between 2012 and 2016 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. RC and LC were defined as having an ileocolic or colocolic/colorectal anastomosis, respectively. Coarsened Exact Matching (CEM) was used to balance the two groups (1:1) on important confounders. The association between type of colectomy and pPOI, defined as POI in the absence of intra-abdominal sepsis, was then assessed in a multiple logistic regression analysis of the matched data.

RESULTS

Of 40,636 patients who underwent a colectomy for neoplastic disease, 15,231 underwent a RC and 25,405 a LC. After CEM, 12,949 matched patients remained in each group, and all important confounders were well balanced. The incidence of pPOI was higher in the RC group (11.5% vs. 8.8%, p < 0.001). On multiple logistic regression, RC was associated with a 35% higher odds of developing pPOI compared to LC (OR 1.35, 95% CI 1.25-1.47). RC was also associated with increased risk for NSQIP-defined major morbidity (OR 1.10, 95% CI 1.01-1.20), 30-day readmission (OR 1.16, 95% CI 1.06-1.27), and increased length of stay (β = 0.16 days, 95% CI 0.11-0.22).

CONCLUSION

pPOI is more common after RC than LC. Future research should aim at better understanding the pathophysiology behind this increased risk and identifying interventions to mitigate pPOI in this population.

HDAC2 hyperexpression alters hippocampal neuronal transcription and microglial activity in neuroinflammation-induced cognitive dysfunction

Background

Inflammation can induce cognitive dysfunction in patients who undergo surgery. Previous studies have demonstrated that both acute peripheral inflammation and anaesthetic insults, especially isoflurane (ISO), are risk factors for memory impairment. Few studies are currently investigating the role of ISO under acute peri-inflammatory conditions, and it is difficult to predict whether ISO can aggravate inflammation-induced cognitive deficits. HDACs, which are essential for learning, participate in the deacetylation of lysine residues and the regulation of gene transcription. However, the cell-specific mechanism of HDACs in inflammation-induced cognitive impairment remains unknown.

Methods

Three-month-old C57BL/6 mice were treated with single versus combined exposure to LPS injected intraperitoneally (i.p.) to simulate acute abdominal inflammation and isoflurane to investigate the role of anaesthesia and acute peripheral inflammation in cognitive impairment. Behavioural tests, Western blotting, ELISA, immunofluorescence, qRT-PCR, and ChIP assays were performed to detect memory, the expressions of inflammatory cytokines, HDAC2, BDNF, c-Fos, acetyl-H3, microglial activity, Bdnf mRNA, c-fos mRNA, and Bdnf and c-fos transcription in the hippocampus.

Results

LPS, but not isoflurane, induced neuroinflammation-induced memory impairment and reduced histone acetylation by upregulating histone deacetylase 2 (HDAC2) in dorsal hippocampal CaMKII⁺ neurons. The hyperexpression of HDAC2 in neurons was mediated by the activation of microglia. The decreased level of histone acetylation suppressed the transcription of Bdnf and c-fos and the expressions of BDNF and c-Fos, which subsequently impaired memory. The adeno-associated virus ShHdac2, which suppresses Hdac2 after injection into the dorsal hippocampus, reversed microglial activation, hippocampal glutamatergic BDNF and c-Fos expressions, and memory deficits.

Conclusions

Reversing HDAC2 in hippocampal CaMKII⁺ neurons exert a neuroprotective effect against neuroinflammation-induced memory deficits.

Prolonged postoperative ileus in gastric surgery: Is there any difference between laparoscopic and open surgery?

BACKGROUND

Prolonged postoperative ileus (PPOI) is a common complication after abdominal surgery, but data about risk factors of PPOI for patients with gastric cancer are rare. We sought to investigate the impact of laparoscopic versus open surgery for PPOI after gastric cancer surgery.

METHODS

A retrospective cohort study was conducted using a registry database consecutively collected from June 2016 to March 2017. PPOI was defined as no bowel function persisting for more than 4 days. Univariate analysis and multiple logistic regression models were performed to investigate risk factors, and stratified analysis was carried out to examine the primary association at different levels of a potential confounding factor.

RESULTS

A total of 162 patients composed of 63 patients undergoing laparotomy and 99 patients undergoing laparoscopy were enrolled and PPOI was observed in 32 (19.75%) patients. Risk factors significantly correlated with PPOI were as follows: open surgery, older age, late surgical pathologic staging, postoperative use of opioid analgesic, low level of postoperative albumin and serum potassium. Compared to open surgery, the laparoscopic surgery was a strong protective factor for PPOI after adjusting related variables (OR = 0.17, CI: 0.05-0.52, P = .002). There was an interaction between surgical methods and the postoperative WBC level (P for interaction = .007). In the two group stratified analysis of WBC, laparoscopic surgery had a significant lower risk of PPOI than open group for the patients with WBC counts above the middle level in crude or adjusted models. This result remained significantly in the three group stratified analysis for the patients with WBC counts in the middle and or high tertile groups.

CONCLUSIONS

PPOI is a common postoperative complication of patients after gastrectomy. Laparoscopic surgery is associated with decreased risk of PPOI in gastric surgery. Patients who underwent open surgery and presented with high level of WBC should be cautious with PPOI.

Prediction model and web-based risk calculator for postoperative ileus after loop ileostomy closure

Background

Postoperative ileus (POI) is a significant complication after loop ileostomy closure given both its frequency and impact on the patient. The purpose of this study was to develop and externally validate a prediction model for POI after loop ileostomy closure.

Methods

The model was developed and validated according to the TRIPOD checklist for prediction model development and validation. The development cohort included consecutive patients who underwent loop ileostomy closure in two teaching hospitals in Montreal, Canada. Candidate variables considered for inclusion in the model were chosen a priori based on subject knowledge. The final prediction model, which modelled the 30-day cumulative incidence of POI using logistic regression, was selected using the highest area under the receiver operating characteristic curve (AUC) criterion. Model calibration was assessed using the Hosmer–Lemeshow goodness-of-fit test. The model was then validated externally in an independent cohort of similar patients from the University of British Columbia.

Results

The development cohort included 531 patients, in whom the incidence of POI was 16·8 per cent. The final model included five variables: age, ASA fitness grade, underlying pathology/treatment, interval between ileostomy creation and closure, and duration of surgery for ileostomy closure (AUC 0·68, 95 per cent c.i. 0·61 to 0·74). The model demonstrated good calibration (P = 0·142). The validation cohort consisted of 216 patients, and the incidence of POI was 15·7 per cent. On external validation, the model maintained good discrimination (AUC 0·72, 0·63 to 0·81) and calibration (P = 0·538).

Conclusion

A prediction model was developed for POI after loop ileostomy closure and included five variables. The model maintained good performance on external validation.

Alvimopan, Regardless of Ileus Risk, Significantly Impacts Ileus, Length of Stay, and Readmission After Intestinal Surgery

BACKGROUND

Previous analyses evaluating alvimopan included patients at varying risk for ileus after intestinal resection, which may have precluded its widespread adoption. We assess the early and delayed effects of alvimopan in patients stratified by risk for ileus after intestinal and colon resection.

METHODS

From the Premier Perspective database, patients with elective small and large bowel resections from 2012 to 2014 were identified. Multivariable analysis identified 14 perioperative risk factors for postoperative ileus. Within low- (0-4 factors), intermediate- (5 factors), and high-risk (6-12 factors) ileus categories, alvimopan and no-alvimopan patients were propensity-score matched for demographics, morbidities, diagnosis, surgery and approach, postoperative complications, surgeon specialty, and hospital features. In-hospital postoperative ileus, length of stay, discharge destination, and ileus-related readmission were compared.

RESULTS

Of 52,948 patients, 15,719 (29.7%) received alvimopan. Risk for ileus in low- (18,784), intermediate- (14,370), and high-risk (19,794) categories was 8.9, 13, and 22% (p ≤ .0001) respectively. After matching, alvimopan was associated with significantly reduced in-hospital postoperative ileus in all (low, 6%; intermediate, 9.4%; and high risk, 16.2%) categories. Hospital stay and 30-, 60-, and 90-day postdischarge ileus were also significantly lower with alvimopan. For low-risk patients, alvimopan increased discharge to home, while 90-day emergency readmission was reduced.

CONCLUSIONS

Alvimopan, regardless of ileus risk, improves ileus, hospital stay, and ileus-related readmission after intestinal resection and these effects are sustained over the long term. Since fewer than a third of patients currently receive alvimopan, its routine adoption with small and large intestinal resection will significantly impact patients and health systems.

Effect of postoperative coffee consumption on gastrointestinal function after abdominal surgery: A systematic review and meta-analysis of randomized controlled trials

Coffee is believed to prevent postoperative ileus. This systematic review and meta-analysis was undertaken to determine the effectiveness of coffee consumption in stimulating gastrointestinal function after abdominal surgery. A number of databases for randomized controlled trials comparing coffee consumption following abdominal surgery versus water drinking or no intervention were searched. Cochrane’s Risk of Bias tool was used to assess risk of bias in included studies. Six trials involving 601 participants were included. All studies had high risk of performance bias. Three studies had an unclear risk of selection bias. Postoperative coffee consumption reduced time to first defecation (mean difference (MD), −9.98 hours; 95% CI, −16.97 to −2.99), time to first flatus (MD, −7.14 hours; 95% CI, −10.96 to −3.33), time to first bowel sound (MD, −4.17 hours; 95% CI, −7.88 to −0.47), time to tolerance of solid food (MD, −15.55 hours; 95% CI, −22.83 to −8.27), and length of hospital stay (MD, −0.74 days; 95% CI, −1.14 to −0.33). Benefits increased with increasing complexity of the procedure. None of the included studies reported adverse events associated with coffee consumption. Postoperative coffee consumption is effective and safe for enhancing the recovery of gastrointestinal function after abdominal surgery.