Assessing Changes in Colon Cancer Care during the COVID-19 Pandemic: A Four-Year Analysis at a Romanian University Hospital

This retrospective study investigates the impact of the COVID-19 pandemic on the surgical management of patients with colon cancer in a tertiary University Hospital in Timisoara, Romania. Data from 867 patients who underwent surgical interventions for this condition between 26 February 2019 and 25 February 2023 were meticulously analyzed to evaluate substantial shifts in the management and outcomes of these patients in comparison to the pre-pandemic era. The results reveal a substantial decrease in elective surgical procedures (p < 0.001) and a significant increase in emergency interventions (p < 0.001). However, postoperative mortality did not show significant variations. Of concern is the diagnosis of patients at more advanced stages of colon cancer, with a significant increase in Stage IV cases in the second year of the pandemic (p = 0.045). Average hospitalization durations recorded a significant decrease (p < 0.001) during the pandemic, and an inverse correlation between patient age and surgery duration was reported (p = 0.01, r = -0.088). This analysis provides a comprehensive perspective on how the pandemic has influenced the management of colon cancer, highlighting significant implications for the management and outcomes of these patients.

Acupoint Stimulation for Enhanced Recovery After Colon Surgery: A Prospective Multicenter Randomized Controlled Trial

Purpose

The aim of this study was to evaluate the efficacy of transcutaneous electrical acupoint stimulation (TEAS) in improving bowel function and thus shortening hospital stay after laparoscopic colon surgery within the ERAS pathway.

Patients and Methods

From November 2016 to March 2018, 100 patients who underwent elective colon surgery were enrolled and 94 finished study (n = 47 for each) in three university hospitals. Patients in the TEAS group received TEAS 30 min before surgery and once a day for 3 days after surgery, while those in the Control Group received no stimulation. Primary outcome was the time to discharge.

Results

Compared with standardized postoperative care, TEAS resulted in a shorter time to first flatus (P=0.03) and time to first defecation (P=0.03), as well as a reduction in the length of hospital stay (P=0.02). Median patient-controlled analgesia (PCA) deliveries and PCA attempts at 24h, 48h and 72h after surgery were less in the TEAS group (P<0.01). No evidence of significant advantages in postoperative pain intensity, nausea, vomiting, sleeping quality and expenses was found in the TEAS group.

Conclusion

Perioperative TEAS further shortens the time to meet discharge criteria after laparoscopic colon surgery in patients under ERAS strategy.

Preoperative risk factors associated with anastomotic leakage after colectomy for colorectal cancer: a systematic review and meta-analysis

INTRODUCTION

anastomotic leak (AL) after colectomy for colorectal cancer (CRC) is a life-threatening complication. This systematic review and meta-analysis aimed to evaluate the preoperative risk factors for AL in patients submitted to colectomy.

METHODS

the bibliographic search covered 15 years and 9 months, from 1st January 2005 to 19th October 2020 and was performed using PubMed, Cochrane Library, Scopus, Biblioteca Virtual em Saúde, Europe PMC and Web of Science databases. The inclusion criteria were cross-sectional, cohort and case-control studies on preoperative risk factors for AL (outcome). The Newcastle-Ottawa scale was used for bias assessment within studies. Meta-analysis involved the calculation of treatment effects for each individual study including odds ratio (OR), relative risk (RR) and 95% confidence intervals (95% CI) with construction of a random-effects model to evaluate the impact of each variable on the outcome. Statistical significance was set at p<0.05.

RESULTS

cross-sectional studies were represented by 39 articles, cohort studies by 21 articles and case-control by 4 articles. Meta-analysis identified 14 main risk factors for AL in CRC patients after colectomy, namely male sex (RR=1.56; 95% CI=1.40-1.75), smoking (RR=1.48; 95% CI=1.30-1.69), alcohol consumption (RR=1.35; 95% CI=1.21-1.52), diabetes mellitus (RR=1.97; 95% CI=1.44-2.70), lung diseases (RR=2.14; 95% CI=1.21-3.78), chronic obstructive pulmonary disease (RR=1.10; 95% IC=1.04-1.16), coronary artery disease (RR=1.61; 95% CI=1.07-2.41), chronic kidney disease (RR=1.34; 95% CI=1.22-1.47), high ASA grades (RR=1.70; 95% CI=1.37-2.09), previous abdominal surgery (RR=1.30; 95% CI=1.04-1.64), CRC-related emergency surgery (RR=1.61; 95% CI=1.26-2.07), neoadjuvant chemotherapy (RR=2.16; 95% CI=1.17-4.02), radiotherapy (RR=2.36; 95% CI=1.33-4.19) and chemoradiotherapy (RR=1.58; 95% CI=1.06-2.35).

CONCLUSIONS

important preoperative risk factors for colorectal AL in CRC patients have been identified based on best evidence-based research, and such knowledge should influence decisions regarding treatment.

The Effects of Anastomotic Leaks on the Net Revenue from Colon Surgery

Background: Complications in colon surgery can have severe health consequences, while at the same time, they are associated with increased costs. An anastomotic leak (AL) is associated with significantly increased costs compared to cases without. The aim of our analysis was to evaluate, which individual processes and patient-unrelated factors influencing the treatment process of colon surgery are responsible for the financial burden in patients with AL. Methods: Data from 263 patients who underwent colon surgery in Wetzikon hospital between January 2018 and December 2020 and was analyzed. In these 263 cases, 12 anastomotic leaks occurred and were compared with 36 cases without AL using a Propensity Score Matching (PSM). The covariates for the PSM have been Age, Sex, and Type of Surgery (t value: −3.26, p-value: 0.001). Results: A total of 48 surgeries were broken down in terms of costs and profitability. This reflected a mean deficit of −37,527 CHF per case (range from −130.05 to +755 CHF) for patients with AL, whereas a mean profit of 1590 CHF per case (range from −24.37 to +12.65 CHF) for those without AL (p < 0.001). Thus, the difference in profit showed a factor of 24.6 with an overall significant negative outcome for the occurrence of AL. The main cost contributing factors were the length of hospital stay (~p < 0.05) and length of intensive care (p < 0.05), whereas neither surgical operation time and anesthesia time nor surgical access, insurance status, indication or type of operation had a significant influence on the net revenue. Conclusion: AL after colon surgery leads to a significant deficit regarding the net revenue. Regarding process optimization, our analysis identified several sectors of non-patient-related, yet cost-influencing variables that should be addressed in future evaluations and optimization of the colon surgery treatment processes.

Do Preoperative Transfusions Impact Prognosis in Moderate to Severe Anaemic Surgical Patients with Colon Cancer?

(1) Background: Anaemia is a common finding in patients with colon cancer and is commonly corrected by blood transfusion prior to surgery. However, the prognostic role of perioperative transfusions is still debated. The aim of the present study was to investigate the role of preoperative anaemia and preoperative blood transfusion in influencing the prognosis in colon cancer. (2) Patients and Methods: Patients undergoing elective surgery for colon cancer at a tertiary referral university hospital between January 2010 and December 2018 were included in a retrospective review of a prospectively collected database. Univariate and regression analyses were performed to identify the prognostic role of preoperative anaemia and preoperative transfusions in this homogeneous cohort of patients. (3) Results: A total of 780 patients were included in the final analysis. The estimated five-year overall survival rate was significantly worse in the anaemic group (83.8% in non-anaemic patients, 60.6% in mild anaemic patients, 61.3% in moderate anaemic patients and 58.4% in severe anaemic patients; log-rank < 0.001 vs. non-anaemic patients). Anaemic status was found to be an independent adverse prognostic factor (hazard ratio (HR): 1.46; 95% confidence interval (CI): 1.02–2.07) during multivariate analysis. Among moderate to severe anaemic patients, no significant association was found between preoperative transfusions and the risk of mortality or recurrence. (4) Conclusions: Preoperative anaemia, regardless of its severity, and not preoperative blood transfusion, was independently associated with a worse prognosis after surgery in patients with colonic cancer.

Financial burden of postoperative complications following colonic resection: A systematic review

BACKGROUND

Colonic resection is a common surgical procedure that is associated with a high rate of postoperative complications. Postoperative complications are expected to be major contributors to hospital costs. Therefore, this systematic review aims to outline the health costs of postoperative complications following colon resection surgery.

METHODS

MEDLINE, Excerpta Medica database, Cochrane, and Economics literature medical databases were searched from 2010 to 2019 to identify English studies containing an economic evaluation of postoperative complications following colonic resection in adult patients. All surgical techniques and indications for colon resection were included. Eligible study designs included randomized trials, comparative observational studies, and conference abstracts.

RESULTS

Thirty-four articles met the eligibility criteria. We found a high overall complication incidence with associated increased costs ranging from $2290 to $43,146. Surgical site infections and anastomotic leak were shown to be associated with greater resource utilization relative to other postoperative complications. Postoperative complications were associated with greater incidence of hospital readmission, which in turn is highlighted as a significant financial burden. Weak evidence demonstrates increased complication incidence and costlier complications with open colon surgery as compared to laparoscopic surgery. Notably, we identified a vast degree of heterogeneity in study design, complication reporting and costing methodology preventing quantitative analysis of cost results.

CONCLUSIONS

Postoperative complications in colonic resection appear to be associated with a significant financial burden. Therefore, large, prospective, cost-benefit clinical trials investigating preventative strategies, with detailed and consistent methodology and reporting standards, are required to improve patient outcomes and the cost-effectiveness of our health care systems.

The Limited Utility of Ranking Hospitals Based on Their Colon Surgery Infection Rates

BACKGROUND

The Centers for Medicare and Medicaid Services (CMS) use colon surgical site infection (SSI) rates to rank hospitals and apply financial penalties. The CMS' risk-adjustment model omits potentially impactful variables that might disadvantage hospitals with complex surgical populations.

METHODS

We analyzed adult patients who underwent colon surgery within facilities associated with HCA Healthcare from 2014 to 2016. SSIs were identified from National Health Safety Network (NHSN) reporting. We trained and validated 3 SSI prediction models, using (1) current CMS model variables, including hospital-specific random effects (HCA-adapted CMS model); (2) demographics and claims-based comorbidities (expanded-claims model); and (3) demographics, claims-based comorbidities, and NHSN variables (claims-plus-electronic health record [EHR] model). Discrimination, calibration, and resulting rankings were compared among all models and the current CMS model with published coefficient values.

RESULTS

We identified 39 468 colon surgeries in 149 hospitals, resulting in 1216 (3.1%) SSIs. Compared to the HCA-adapted CMS model, the expanded-claims model had similar performance (c-statistic, 0.65 vs 0.67, respectively), while the claims-plus-EHR model was more accurate (c-statistic, 0.70; 95% confidence interval, .67-.73; P = .004). The sampling variation, due to the low surgical volume and small number of infections, contributed 74% of the total variation in observed SSI rates between hospitals. When CMS model rankings were compared to those from the expanded-claims and claims-plus-EHR models, 18 (15%) and 26 (22%) hospitals changed quartiles, respectively, and 10 (8.3%) and 12 (10%) hospitals changed into or out of the lowest-performing quartile, respectively.

CONCLUSIONS

An expanded set of variables improved colon SSI risk predictions and quartile assignments, but low procedure volumes and SSI events remain a barrier to effectively comparing hospitals.

Factors associated with colon cancer early, intermediate and late recurrence after surgery for stage I-III: A 5-year prospective study

OBJECTIVE

To identify factors associated with early, intermediate or late recurrence colon cancer recurrence.

METHODS

A total of 1,732 consecutive patients with colon cancer were recruited and followed for a period of 5 years. Recurrence at 1 year (early), from 1 to 2 (early), from 2 to 3 (intermediate) and from 3 to 5 years (late) was the main outcome measures.

RESULTS

Predictors of early recurrence (AUC (95% CI):0.74 (0.70-0.78) were as follows: TNM stage II and III, more than one type of invasion, haemoglobin <10 g/dl, residual tumour (R1), ASA IV, log odds of positive lymph nodes ratio ≥-0.53, perforation, neoadjuvant chemotherapy, infectious complications within 1 year and CEA pre- and post-intervention. These factors remained significant for predicting intermediate (AUC [95% CI]: 0.72 [0.67-0.77]) and late (AUC [95% CI]: 0.68 [0.63-0.74]) recurrence, except for ASA class, log lymph node ratio, perforation and neoadjuvant chemotherapy. Additionally, laterality (left) and medical complications up to 2 years were significant.

CONCLUSIONS

These risk factors show good predictive ability of early, intermediate and late recurrence, confirming factors established by guidelines and adding some others. They could serve to provide more appropriate and accurate treatment and follow-up tailored to patient characteristics.

Usage of Probiotics and its Clinical Significance at Surgically Treated Patients Sufferig from Colorectal Carcinoma

Introduction:

Colorectal Cancer (CRC) is the third most common malignant disease and the fourth most common cause of death associated with malignancy. Adenocarcinomas account for 95% of all cases of colon cancer. Treatment usually includes a surgical resection which is preceded or followed by chemotherapy and radiotherapy depending on the stage. There is constant interest in the microbiological ecosystem of the intestine, which is considered to be crucial for the onset and progression of the disease as well as the development of postoperative complications. Iatrogenic factors associated with the treatment of CRC may result in pronounced expression of virulence of the bacterial intestinal flora and fulminant inflammatory response of the host which ultimately leads to adverse treatment results. The modulation of intestinal microflora by probiotics seems to be an effective method of reducing complications in surgical patients. The question is whether ordering probiotics can lead to more favourable treatment outcomes for our patients who are operated due to colorectal adenocarcinoma, and whether this should become common practice.

Aim:

To demonstrate the clinical significance of probiotic administration in patients treated for colorectal adenocarcinoma and the results compared with relevant studies.

Patients and Methods:

In a randomized controlled prospective study conducted at the Clinic of General and Abdominal Surgery of the UCCS in the period of 01 January 2017 until 31 December 2017, there were a total of 78 patients with colorectal adenocarcinoma. Patients were divided into two groups: a group treated with oral probiotics (n = 39) according to the 2x1 scheme starting from the third postoperative day lasting for the next thirty days, followed by 1x1 lasting for two weeks in each subsequent month to one year, and the control group (n = 39) which was not routinely treated with probiotics.

Results:

A statistically significant difference in the benefit of using probiotics was found during postoperative hospitalization and the occurrence of fatal outcome in the first six months. All complications were more present in the group of patients untreated with probiotic, with statistical significance shown only in the case of ileus. Probiotic has a statistically significant reduction in postoperative complications in the localization of tumours on the rectum -33.3% and the ascending colon -16.7%.

Conclusion:

There is a significant benefit of administering probiotics in surgically treated patients for colorectal adenocarcinoma.

Ileocaecal valve syndrome after surgery in adult patients: myth or reality?

AIM

The onset of symptoms after removal of the ileocaecal valve (ICV) may be perceived as an unwanted effect of surgery and induce patients to bring unnecessary litigation against surgeons. The aim of our study is to assess the real impact on the quality of life of patients whose ICV has been surgically removed, using three validated questionnaires.

METHOD

In patients who had their ICV removed surgically, the Gastrointestinal Quality of life (GIQLI) questionnaire and those used by the European Organization for research and Treatment of Cancer (EORTC) were administered before and after surgery. The empirical rule effect size method was used to evaluate the clinical significance of the statistical data.

RESULTS

We interviewed 225 patients. Data collected through the three questionnaires highlighted a trend towards postoperative improvement of the selected gastrointestinal symptoms compared with the baseline. The GIQLI questionnaire showed a statistically significant improvement in 'pain', 'nausea' and 'constipation' during the follow-up. Constipation appeared more frequently in patients older than 70 years compared with younger ones. The EORTC-QLQ-C30 questionnaire showed a significant correlation between diarrhoea and extended right colectomy at 3 months after surgery, which was not confirmed at 6 months. The EORTC QLQ-CR29 questionnaire showed a slight deterioration of 'leakage of stools from the anal opening' at 6 months after surgery, but this symptom was not deemed clinically significant.

CONCLUSION

We found that bowel functions in most patients after surgical removal of the ICV were satisfactory. Providing patients with a comprehensive and exhaustive informed consent during preoperative consultations could promote patient trust and avoid misunderstandings.

The "bundle" approach to reduce the surgical site infection rate

RATIONALE, AIMS, AND OBJECTIVES

In Italy, since 2008, the surveillance of surgical site infections (SSIs) has been conducted following ECDC recommendations, according to the protocol of the National System of Surveillance of Surgical Site Infections. In 2009, in Piedmont region, where the study was conducted, it was introduced a survey of a "bundle" for every patient under SSIs surveillance. The bundle includes 5 items: infection risk index calculation, preoperative shower, trichotomy, antibiotic prophylaxis, and body temperature control. The aim of this study is the evaluation of the incidence rate of the SSIs in relation to the implementation of the bundle from January 1st to December 31st, 2012.

METHOD

This study is an observational study (retrospective cohort). The regional surveillance system collected 3314 surgical operations during the year 2012 from 37 hospitals. The represented surgical categories were hip prosthetic surgery (HPRO: 1992 cases) and colon surgery (COLO: 1322 cases). The bundle was implemented in 1114 and 671 operations, respectively. Univariate and multivariate analysis were conducted stratifying the sample for hip surgery and colorectal surgery, with the purpose to identify an association between the implementation of the bundle and a decrease of the rate of SSIs.

RESULTS

From the analysis, the bundle resulted as a protective factor for the infection risk in colon surgery (odds ratio [OR], 0.55; 95% confidence interval [CI], 0.38-0.78). The main risk factors were American Society of Anesthesiologists score ≥ 3 (OR, 1.57; 95% CI, 1.10-2.24) and contamination class ≥ 3 (OR, 2.02; 95% CI, 1.37-2.97). In the hip surgery, the application of the bundle was not statistically associated to a decrease of the risk of infection.

CONCLUSION

The use of surgical bundle seems to reduce significantly the SSIs rate in the colon surgery.

Laparoscopy for Colon Cancer

The use of laparoscopy has become widespread across many surgical specialties. Its utility as treatment for colon cancer was initially met with hesitancy due to concern for port site and wound recurrences; however, this was later disproven by large retrospective series. Subsequently, there have been multiple, large, prospective, randomized studies evaluating laparoscopic versus open colectomy for colon cancer. All studies yielded similar results and showed no statistical difference in overall survival, disease-free survival, and recurrence. Additionally, these studies revealed similar operative outcomes with respect to complication rates, perioperative mortality, and conversion to open colectomy, as well as equivalent oncologic resections. Overall in the laparoscopic colectomy groups, hospital stays were shorter, and often times patients required less narcotics postoperatively, but laparoscopic operative times were longer. With adequate training, the use of laparoscopy can be safely employed for patients with colon cancer.

Remote ischemic preconditioning improves the cognitive function of elderly patients following colon surgery: A randomized clinical trial

BACKGROUND

Cognitive function impairment is one of the most common complications in elderly patients after surgery, and an ideal nonpharmacological therapy has not yet been identified. Thus, we hypothesized that remote ischemic preconditioning could improve cognitive functions in elderly patients after surgery and investigated the mechanism underlying this effect.

METHODS

Ninety patients classified as American Society of Anaesthesiologists (ASA) physical status of 2 or 3 and aged 65 to 75 years who were scheduled for elective colon surgery under general anesthesia were randomly allocated to either a remote ischemic preconditioning group (Group R, n = 45) or a control group (Group C, n = 45). Remote ischemic preconditioning was performed by applying a static pressure of 200 mm Hg with a blood pressure cuff wrapped around the right upper limb for 3 ischemia cycles of 5 minutes each.

RESULTS

The Montreal Cognitive Assessment (MoCA) scores between the 2 groups were not significantly different on the day before surgery or the seventh day after surgery, but the scores on the first day after surgery (26.87 ± 0.84 vs 25.96 ± 0.85, P < .001) and third day after surgery (27.49 ± 0.66 vs 27.02 ± 0.92, P = .009) were significantly higher for Group R than those for Group C. Moreover, remote ischemic preconditioning markedly decreased the serum concentrations of the interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α), and S100B proteins compared with the control group (P < .001).

CONCLUSION

Remote ischemic preconditioning improves postoperative cognitive function in elderly patients following colon surgery. The cognitive protective effects of remote ischemic preconditioning are partially related to the inhibition of inflammation.

Truth in Reporting: How Data Capture Methods Obfuscate Actual Surgical Site Infection Rates within a Health Care Network System

BACKGROUND

Two systems measure surgical site infection rates following colorectal surgeries: the American College of Surgeons National Surgical Quality Improvement Program and the Centers for Disease Control and Prevention National Healthcare Safety Network. The Centers for Medicare & Medicaid Services pay-for-performance initiatives use National Healthcare Safety Network data for hospital comparisons.

OBJECTIVE

This study aimed to compare database concordance.

DESIGN

This is a multi-institution cohort study of systemwide Colorectal Surgery Collaborative. The National Surgical Quality Improvement Program requires rigorous, standardized data capture techniques; National Healthcare Safety Network allows 5 data capture techniques. Standardized surgical site infection rates were compared between databases. The Cohen κ-coefficient was calculated.

SETTING

This study was conducted at Boston-area hospitals.

PATIENTS

National Healthcare Safety Network or National Surgical Quality Improvement Program patients undergoing colorectal surgery were included.

MAIN OUTCOME MEASURES

Standardized surgical site infection rates were the primary outcomes of interest.

RESULTS

Thirty-day surgical site infection rates of 3547 (National Surgical Quality Improvement Program) vs 5179 (National Healthcare Safety Network) colorectal procedures (2012-2014). Discrepancies appeared: National Surgical Quality Improvement Program database of hospital 1 (N = 1480 patients) routinely found surgical site infection rates of approximately 10%, routinely deemed rate "exemplary" or "as expected" (100%). National Healthcare Safety Network data from the same hospital and time period (N = 1881) revealed a similar overall surgical site infection rate (10%), but standardized rates were deemed "worse than national average" 80% of the time. Overall, hospitals using less rigorous capture methods had improved surgical site infection rates for National Healthcare Safety Network compared with standardized National Surgical Quality Improvement Program reports. The correlation coefficient between standardized infection rates was 0.03 (p = 0.88). During 25 site-time period observations, National Surgical Quality Improvement Program and National Healthcare Safety Network data matched for 52% of observations (13/25). κ = 0.10 (95% CI, -0.1366 to 0.3402; p = 0.403), indicating poor agreement.

LIMITATIONS

This study investigated hospitals located in the Northeastern United States only.

CONCLUSIONS

Variation in Centers for Medicare & Medicaid Services-mandated National Healthcare Safety Network infection surveillance methodology leads to unreliable results, which is apparent when these results are compared with standardized data. High-quality data would improve care quality and compare outcomes among institutions.

Clinical role of fluorescence imaging in colorectal surgery - a review

INTRODUCTION

Anastomotic leak (AL) after colorectal surgery is a devastating complication; decreased blood perfusion is an important risk factor. Surgeons rely on subjective measures to assess bowel perfusion. Fluorescence imaging (FI) with indocyanine green (ICG) provides a real-time objective assessment of intestinal perfusion. Areas covered: A PubMed search using the terms 'fluorescence imaging', 'indocyanine green', 'colon and rectal surgery' was undertaken. Sixteen articles between 2010 to present were identified. Main outcomes were leak rate reduction, change in surgical plan, and technical feasibility. Change in surgical strategy due to FI was recorded in 11 studies. Two case control studies showed overall reduction of 4% and 12% in AL rate and one showed no change in AL rate between groups. Expert commentary: According to the available literature, FI is technically feasible and alters surgical strategy in a non-negligible number of patients possibly effecting AL rates.

Gut microbiome, surgical complications and probiotics

The trigger for infectious complications in patients following major abdominal operations is classically attributed to endogenous enteral bacterial translocation, due to the critical condition of the gut. Today, extensive gut microbiome analysis has enabled us to understand that almost all "evidence-based" surgical or medical intervention (antibiotics, bowel preparation, opioids, deprivation of nutrition), in addition to stress-released hormones, could affect the relative abundance and diversity of the enteral microbiome, allowing harmful bacteria to proliferate in the place of depressed beneficial species. Furthermore, these bacteria, after tight sensing of host stress and its consequent humoral alterations, can and do switch their virulence accordingly, towards invasion of the host. Probiotics are the exogenously given, beneficial clusters of live bacteria that, upon digestion, seem to succeed in partially restoring the distorted microbial diversity, thus reducing the infectious complications occurring in surgical and critically ill patients. This review presents the latest data on the interrelationship between the gut microbiome and the occurrence of complications after colon surgery, and the efficacy of probiotics as therapeutic instruments for changing the bacterial imbalance.

Robotic colonic resection

Innovative robotic technologies are aiming to help surgeons overcome the limits of conventional laparoscopic surgery. Recent studies have shown that robotic colorectal surgery is safe and provides favorable results in comparison to conventional laparoscopic techniques. Further studies and long-term follow-up are required to assess the outcomes and potential benefits of robotic colon surgery over laparoscopic surgery.

Preoperative low-dose ketamine has no preemptive analgesic effect in opioid-naïve patients undergoing colon surgery when nitrous oxide is used - a randomized study

BACKGROUND

The analgesic properties of ketamine are associated with its non-competitive antagonism of the N-methyl-D-aspartate receptor; these receptors exhibit an excitatory function on pain transmission and this binding seems to inhibit or reverse the central sensitization of pain. In the literature, the value of this anesthetic for preemptive analgesia in the control of postoperative pain is uncertain. The objective of this study was to ascertain whether preoperative low-dose ketamine reduces postoperative pain and morphine consumption in adults undergoing colon surgery.

METHODS

In a double-blind, randomized trial, 48 patients were studied. Patients in the ketamine group received 0.5 mg/kg intravenous ketamine before surgical incision, while the control group received normal saline. The postoperative analgesia was achieved with a continuous infusion of morphine at 0.015 mg∙kg-¹∙h-¹ with the possibility of 0.02 mg/kg bolus every 10 min. Pain was assessed using the Visual Analog Scale (VAS), morphine consumption, and hemodynamic parameters at 0, 1, 2, 4, 8, 12, 16, and 24 hours postoperatively. We quantified times to rescue analgesic (Paracetamol), adverse effects and patient satisfaction.

RESULTS

No significant differences were observed in VAS scores between groups (P>0.05), except at 4 hours postoperatively (P=0.040). There were no differences in cumulative consumption of morphine at any time point (P>0.05). We found no significant differences in incremental postoperative doses of morphine consumption in bolus, except at 12 h (P =0.013) and 24 h (P =0.002). The time to first required rescue analgesia was 70 ± 15.491 min in the ketamine group and 44 ± 19.494 min in the control (P>0.05). There were no differences in hemodynamic parameters or patient satisfaction (P>0.05).

CONCLUSIONS

Preoperative low-dose-ketamine did not show a preemptive analgesic effect or efficacy as an adjuvant for decreasing opioid requirements for postoperative pain in patients receiving intravenous analgesia with morphine after colon surgery.

Are there any differences between age groups regarding colorectal surgery in elderly patients?

BACKGROUND

Surgical procedures with curative or palliative intentions in subjects aged over 70 represent a colorectal surgical challenge due to the issue they raise: Benefits versus increased morbidity. In this study, we proposed to compare the impact of surgery with the surgical intervention short-term results and analyze the factors that may influence these results in elderly age groups.

METHODS

We retrospectively analyzed a database containing information about patients who underwent colorectal surgery from January 2008 to December 2013 at the Baskent University Istanbul Research Hospital and the Okmeydani Training and Research Hospital.

RESULTS

A total of 265 patients were enrolled and analyzed in this retrospective study. Of these patients operated during the study period, 110 were between 60 and 69 years of age (group 1), 99 were between 70 and 79 years of age and 56 were older than 80 years of age. In total, there were 138 (52%) men and 127 (48%) women that underwent colorectal surgery. Intraoperative complications did not differ between group 1 and group 2, group 2 and group 3; however, some differences were observed between group 1 and group 3 (p = 0.001). Systemic complications were more frequent in group 3 than in groups 1 (p = 0.039) and 2 (p = 0.002). Furthermore, there were no significant systemic complication differences between groups 1 and 2. The mean length of postoperative hospital stay was 9.91 ± 2.65 days in the first group, 9.38 ± 2.44 days in the second group and 11.8 ± 4.35 days in the third group.

CONCLUSION

Colon surgery for both malignant and non-malignant diseases can be performed safely in different elderly age groups; thus, age should not be considered as an obstacle in elderly patients undergoing colorectal resection.

Adherence to Enhanced Recovery After Surgery and length of stay after colonic resection

AIM

The Enhanced Recovery After Surgery (ERAS) programme is a multimodal approach to improve peri-operative care in colon surgery. The aim of this study was to report on the adherence to and outcomes of ERAS in the first years after implementation.

METHOD

Data of patients undergoing elective colon resections for malignancy in 2006 until 2010 were compared with patients receiving conventional care in 2005. Retrospective analysis was performed including length of stay (LOS), protocol adherence and complications. The predictive values of ERAS items and baseline characteristics on LOS and complications were analysed using univariate and multivariate analysis.

RESULTS

Length of stay (LOS) was significantly shorter in 2006 and 2007 (P ≤ 0.009 and P ≤ 0.004) but not in 2008 and 2009. The mean adherence rate to the ERAS items was 84.1% in 2006 and 2007 and 72.4% in 2008 and 2009 (P < 0.001). In 2005, 2008 and 2009 LOS was significantly shorter for laparoscopically operated patients than for patients with open resections (P < 0.002, P < 0.001 and P < 0.004 respectively). Multivariate analysis showed that age, laparoscopic surgery, removal of nasogastric tube before extubation, mobilization within 24 h after surgery, starting nonsteroidal anti-inflammatory drugs at day 1 and removal of thoracic epidural analgesia at day 2 were independent predictors of LOS.

CONCLUSION

Strict adherence to the ERAS protocol was associated with reduced LOS and improved outcome in elective colon surgery for malignancy. These benefits were lost when protocol adherence was lower. Embedding the ERAS protocol into an organization and repetitive education are vital to sustain its beneficial effects on LOS and outcome.