Citations

Abstract Background This study aimed to identify patients eligible for a 48-h stay after colorectal resection, to provide guidance for early discharge planning. Methods A bi-institutional retrospective cohort study was undertaken of consecutive patients undergoing major elective colorectal resection for benign or malignant pathology within a comprehensive enhanced recovery pathway between 2011 and 2017. Overall and severe (Clavien–Dindo grade IIIb or above) postoperative complication and readmission rates were compared between patients who were discharged within 48 h and those who had hospital stay of 48 h or more. Multinominal logistic regression analysis was performed to ascertain significant factors associated with a short hospital stay (less than 48 h). Results In total, 686 of 5122 patients (13·4 per cent) were discharged within 48 h. Independent factors favouring a short hospital stay were age below 60 years (odds ratio (OR) 1·34; P = 0·002), ASA grade less than III (OR 1·42; P = 0·003), restrictive fluid management (less than 3000 ml on day of surgery: OR 1·46; P < 0·001), duration of surgery less than 180 min (OR 1·89; P < 0·001), minimally invasive approach (OR 1·92; P < 0·001) and wound contamination grade below III (OR 4·50; P < 0·001), whereas cancer diagnosis (OR 0·55; P < 0·001) and malnutrition (BMI below 18 kg/m2: OR 0·42; P = 0·008) decreased the likelihood of early discharge. Patients with a 48-h stay had fewer overall (10·8 per cent versus 30·6 per cent in those with a longer stay; P < 0·001) and fewer severe (2·6 versus 10·2 per cent respectively; P < 0·001) complications, and a lower readmission rate (9·0 versus 11·8 per cent; P = 0·035). Conclusion Early discharge of selected patients is safe and does not increase postoperative morbidity or readmission rates. In these patients, outpatient colorectal surgery should be feasible on a large scale with logistical optimization.

BACKGROUND: Postoperative ileus remains an issue after colorectal surgery delaying recovery and increasing the length of hospital stay and costs. OBJECTIVE: The purpose of this study was to analyze the impact of perioperative fluid management on ileus occurrence after colorectal surgery within a fully implemented enhanced recovery pathway. DESIGN: This was a retrospective cohort study of a prospectively maintained institutional database. SETTINGS: The study was conducted at a tertiary academic facility with fully implemented standardized enhanced recovery pathway over the entire study period. PATIENTS: All of the consecutive elective major colorectal resections for benign or malign indications between 2011 and 2016 were included. MAIN OUTCOME MEASURES: Postoperative ileus was defined as the need for nasogastric tube reinsertion. Perioperative fluid management and surgical outcome were compared between patients presenting with ileus and those without. Potential risk factors for ileus were identified through multinomial logistic regression. RESULTS: Postoperative ileus occurred in 377 (9%) of 4205 included patients at day 4 (interquartile range, 2–5 d). Intraoperatively, ileus patients received 3.2 ± 2.6 L of fluids, whereas the remaining patients received 2.5 ± 1.7 L (p < 0.001). Weight gain was 3.8 ± 7.1 kg in ileus patients versus 3.0 ± 6.6 kg (p = 0.272) in the remaining patients at postoperative day 1, 4.4 ± 6.5 kg versus 3.1 ± 7.0 kg (p = 0.028) at postoperative day 2, and 1.8 ± 6.0 kg versus 0.0 ± 6.0 kg at discharge (p = 0.002). The multivariable model including all significant (p < 0.05) demographic, fluid management–related, and surgical parameters retained postoperative day 0 fluids of >3 L (OR = 1.65 (95% CI, 1.13–2.41); p = 0.009), postoperative day 2 weight gain of >2.5 kg (OR = 1.49 (95% CI, 1.01–2.21); p = 0.048), and occurrence of postoperative complications (OR = 2.00 (95% CI, 1.39–2.90); p < 0.001) as independent risk factors for ileus. LIMITATIONS: This study was limited by its retrospective design. Fluid management depends on patient-, disease-, and surgery-related factors and cannot be generalized and extrapolated. CONCLUSIONS: Fluid overload and occurrence of postoperative complications were independent risk factors for postoperative ileus. This calls for action to keep perioperative fluids below suggested thresholds. See Video Abstract at http://links.lww.com/DCR/B54. ASOCIACIÓN POTENCIAL ENTRE EL MANEJO DEL LÍQUIDO PERIOPERATORIO Y EL SUCESO DE ÍLEO POSTOPERATORIO ANTECEDENTES: El íleo postoperatorio sigue siendo un problema después de una cirugía colorrectal que retrasa la recuperación y aumenta la duración de la estancia hospitalaria y los costos. OBJETIVO: Analizar el impacto del manejo del líquido perioperatorio en la incidencia de íleo después de la cirugía colorrectal dentro de una vía de recuperación mejorada totalmente implementada. DISEÑO: Estudio de cohorte retrospectivo de una base de datos institucional mantenida prospectivamente. MARCO: Centro académico terciario con una ruta de recuperación mejorada estandarizada completamente implementada durante todo el período del estudio. PACIENTES: Se incluyeron todas las resecciones colorrectales mayores electivas consecutivas para indicaciones benignas o malignas entre 2011 y 2016. MEDIDAS DE RESULTADOS PRINCIPALES: El íleo postoperatorio se definió como la necesidad de reinserción de la sonda nasogástrica. El manejo del líquido perioperatorio y el resultado quirúrgico se compararon entre los pacientes con íleo y los que no. Los posibles factores de riesgo para el íleo se identificaron mediante regresión logística multinominal. RESULTADOS: El íleo postoperatorio se ocurrió en 377 (9%) de los 4205 pacientes incluidos al cuarto día (RIC 2-5). Intraoperatoriamente, los pacientes con íleo recibieron 3.2 ± 2.6 L de líquidos, mientras que los pacientes restantes recibieron 2.5 ± 1.7 L (p < 0.001). El aumento de peso fue de 3.8 ± 7.1 kg en pacientes con íleo versus 3 ± 6.6 kg (p = 0.272) en los pacientes restantes en el día postoperatorio 1, 4.4 ± 6.5 kg vs. 3.1 ± 7 kg (p = 0.028) en el día postoperatorio 2 y 1.8 ± 6 kg versus a 0 ± 6 kg al tiempo de alta hospitalaria (p = 0.002). El modelo multivariable que incluye todos los parámetros demográficos, del manejo de líquidos y quirúrgicos significativos (p <0.05) mantuvo líquidos del día 0 después de la operación de> 3L (proporción de probabilidad 1.65, intervalo de confianza del 95% 1.13-2.41, p = 0.009), ganancia de peso de > 2.5 kg en el dia postoperatorio 2 (proporción de probabilidad 1.49, 95% intervalo de confianza 1.01-2.21, p = 0.048) y aparición de complicaciones postoperatorias (proporción de probabilidad 2, 95% intervalo de confianza 1.39-2.9, p <0.001) como factores de riesgo independientes para íleo. LIMITACIONES: Diseño retrospectivo. El manejo de líquidos depende de factores relacionados con el paciente, la enfermedad y la cirugía, y no puede generalizarse ni extrapolarse. CONCLUSIONES: La sobrecarga de líquidos y la aparición de complicaciones postoperatorias fueron factores de riesgo independientes para el íleo postoperatorio. Esto requiere medidas para mantener los líquidos perioperatorios por debajo de los umbrales sugeridos. Vea el Video del Resumen en http://links.lww.com/DCR/B54.

Abstract Introduction The impact of ustekinumab on adverse postoperative outcomes in Crohn’s disease (CD) remains largely unknown. We determined the difference in 90-day postoperative complication rates among CD patients exposed to ustekinumab within 12 weeks prior to an abdominal operation as compared to patients not exposed to biologic therapy. Methods A retrospective chart review of all adults with CD who underwent an abdominal operation between October 1, 2017 and December 31, 2018 at a single tertiary medical center was performed. Data collection included patient demographics, concurrent immunosuppression, serum laboratory values, operative values, and 90-day outcomes including superficial surgical site infection (sSSI), intra-abdominal sepsis, overall infectious complications, readmission, and reoperation rates. The primary outcome was the 90-day rate of intra-abdominal sepsis. Results Fifty-seven CD patients received ustekinumab and 277 received no biologic therapy in the 12 weeks prior to major abdominal surgery. Ustekinumab-exposed patients were younger, less likely to have diabetes mellitus or active tobacco exposure, were more often obese, and more often taking a concurrent immunomodulator. Ustekinumab remained an independent predictor of intra-abdominal sepsis on multivariable logistic regression. Immunomodulator exposure was associated with significantly increased rates of sSSI and overall complication rates. Conclusions Ustekinumab is associated with increased rates of 90-day postoperative intra-abdominal sepsis following a major abdominal operation for CD.

Grassland restoration success depends on the development of plant communities that accord with restoration goals. Intraspecific variation in competitiveness may affect community development. For some grassland species, germplasm can be obtained from sources ranging from wild collections to selectively bred cultivars. The extent to which population source affects competitive outcomes in restoration projects is unclear. We addressed this knowledge gap in a glasshouse experiment comparing competitive response and effect among three sources of switchgrass (Panicum virgatum) that are available for restoration: selectively bred cultivars, commercial ecotypes (commercially produced but not deliberately selected), and wild collections. Two strains per source type were grown with four associates chosen to encompass varied functional groups: conspecifics, Bromus inermis, Cirsium arvense, and Solanum ptycanthum. Switchgrass competitive response was evaluated for survival, height, biomass, and shoot:root biomass ratio; competitive effect was assessed as associate survival, height, biomass, and shoot:root ratio. Competitive responses of cultivars and commercial ecotypes were broadly similar, although cultivar biomass exceeded both that of ecotypes and wild collections, and ecotypes had the highest shoot:root ratio. Wild collections were most negatively affected by competition. The shoot:root ratios of all sources were highest when grown with S. ptycanthum, indicating that competitive responses were plastic; plasticity in fitness‐related traits can contribute to persistence in variable environments. Cultivars exerted negative effects on B. inermis. Secondary analyses indicated that all switchgrass sources were most inhibited by the annual S. ptycanthum. To summarize, population source affected multiple aspects of switchgrass competitive ability, when grown against functionally varied associates.

Abstract Background The decision to either escalate medical therapy or proceed to ileocecal resection (ICR) in patients with terminal ileal Crohn disease (CD) remains largely subjective. We sought to develop a risk score for predicting ICR at 1 year from computed tomography or magnetic resonance enterography (CTE/MRE). Methods We conducted a retrospective cohort study including all consecutive adult (> 18 years) patients with imaging findings of terminal ileal CD (Montreal classification: B1, inflammatory predominant; B2, stricturing; or B3, penetrating) on CTE/MRE between January 1, 2016, and December 31, 2016. The risk for ICR at 6 months and at 1 year of CTE/MRE and risk factors associated with ICR, including demographics, CD-specific immunosuppressive therapeutics, and disease presentation at the time of imaging, were determined. Results Of 559 patients, 121 (21.6%) underwent ICR during follow-up (1.4 years [IQR 0.21–1.64 years]); the risk for ICR at 6 months and at 1 year was 18.2% (95% CI 14.7%–21.6%) and 20.5% (95% CI 16.8%–24.1%), respectively. Multivariable analysis revealed Montreal classification (B2, hazard ratio [HR] 2.73, and B3, HR 6.80, both P < 0.0001), upstream bowel dilation (HR 3.06, P < 0.0001), and younger age (19–29 years reference, 30–44 years, HR 0.83 [P = 0.40]; 45–59 years, HR 0.58 [P = 0.04], and 60+ years, HR 0.45 [P = 0.01]) to significantly increase the likelihood of ICR. A predictive nomogram for interval ICR was developed based on these significant variables. Conclusions The presence of CD strictures, penetrating complications, and upstream bowel dilation on CTE/MRE, combined with young age, significantly predict ICR. The suggested risk model may facilitate objective therapeutic decision-making.

AbstractBackgroundOncological outcomes of locally advanced rectal cancer depend on the quality of surgical and oncological management. Enhanced recovery pathways (ERPs) have yet to be assessed for their oncological impact when used in combination with minimally invasive surgery. This study assessed outcomes with or without an ERP in patients with rectal cancer.MethodsThis was a retrospective analysis of all consecutive adult patients who underwent elective minimally invasive surgery for primary rectal adenocarcinoma with curative intent between February 2005 and April 2018. Both laparoscopic and robotic procedures were included. Short-term morbidity and overall survival were compared between patients treated according to the institutional ERP and those who received conventional care.ResultsA total of 600 patients underwent minimally invasive surgery, of whom 320 (53·3 per cent) were treated according to the ERP and 280 (46·7 per cent) received conventional care. ERP was associated with less overall morbidity (34·7 versus 54·3 per cent; P &lt; 0·001). Patients in the ERP group had improved overall survival on univariable (91·4 versus 81·7 per cent at 5 years; hazard ratio (HR) 0·53, 95 per cent c.i. 0·28 to 0·99) but not multivariable (HR 0·78, 0·41 to 1·50) analysis. Multivariable analysis revealed age (HR 1·46, 1·17 to 1·82), male sex (HR 1·98, 1·05 to 3·70) and complications (HR 2·23, 1·30 to 3·83) as independent risk factors for compromised overall survival. Disease-free survival was comparable for patients who had ERP or conventional treatment (80·5 versus 84·6 per cent at 5 years respectively; P = 0·272).ConclusionTreatment within an ERP was associated with a lower morbidity risk that may have had a subtle impact on overall but not disease-specific survival.

AbstractBackgroundThe present study aimed to assess the impact of perioperative fluid management on early acute kidney injury (AKI) rate and long‐term sequelae in patients undergoing elective colorectal procedures within an enhanced recovery pathway (ERP).MethodsRetrospective analysis of consecutive patients from a prospectively maintained ERP database (2011–2015) is performed. Pre‐ and postoperative creatinine levels (within 24 h) were compared according to risk (preoperative creatinine rise ×1.5), injury (×2), failure (×3), loss of kidney function and end‐stage kidney disease (RIFLE) criteria. Risk factors for early AKI were identified through logistic regression analysis, and long‐term outcome in patients with AKI was assessed.ResultsOut of 7103 patients, 4096 patients (58%) with pre‐ and postoperative creatinine levels were included. Of these, 104 patients (2.5%) presented postoperative AKI. AKI patients received higher amounts of POD 0 fluids (3.8 ± 2.4 vs. 3.2 ± 2 L, p = 0.01) and had increased postoperative weight gain at POD 2 (6 ± 4.9 vs. 3 ± 2.7 kg, p = 0.007). Independent risk factors for AKI were high ASA score (ASA ≥ 3: OR 1.7; 95% CI 1.1–2.5), prolonged operating time (>180 min: OR 1.9; 95% CI 1.3–2.9) and diabetes mellitus (OR 2.5; 95% CI 1.5–4), while minimally invasive surgery was a protective factor (OR 0.6; 95% CI 0.4–0.9). Five patients (0.1%) developed chronic kidney disease, and two of them needed dialysis after a mean follow‐up of 33.7 ± 22.4 months.ConclusionsEarly AKI was very uncommon in the present cohort of colorectal surgery patients treated within an ERP, and long‐term sequelae were exceptionally low.

AbstractAimThe present study aimed to compare functional recovery and surgical outcomes after left and right colectomies.MethodConsecutive elective left and right colon resections for benign and malignant indications, performed between 2011 and 2016 and recorded in a prospectively maintained enhanced recovery database, were analysed. Demographic and surgical items, as well as functional recovery and 30‐day complications, were compared between left‐sided and right‐sided colectomies. Multivariable analysis was performed to identify risk factors for postoperative ileus (POI).ResultsIn total, 1001 left and 1041 right colectomies were comparable regarding demographic factors; only body mass index (BMI) was higher in patients undergoing left‐sided resections (> 30 kg/m2: 33% vs 27%, P = 0.004). Malignancy (29% vs 67%, P < 0.001) and Crohn's disease (1% vs 31%, P < 0.001) were preponderant in right colectomies, whereas diverticular disease (68% vs 1%, P < 0.001) was the most common indication for left colectomy. Compliance with the enhanced recovery pathway (ERP) was comparable. While the minimally invasive approach was the preferred approach for both sides (61% vs 64%, P = 0.158), left colectomies took longer (180 ± 80 min vs 150 ± 70 min, P < 0.001), needed more perioperative fluids (3.1 ± 1.4 l vs 2.7 ± 1.5 l, P < 0.001) and resulted in greater postoperative weight gain (3.9 ± 6.5 kg vs 2.6 ± 6 kg, P = 0.025). Crohn's disease (OR = 2.64, 95% CI: 1.27–5.46) and fluid overload (OR = 2.02, 95% CI: 1.06–3.82) were independent risk factors for POI.ConclusionDespite equal ERP compliance, postoperative ileus was higher after right‐sided colectomies. This finding was associated with Crohn's disease and fluid overload.

Early re-alimentation is advocated by enhanced recovery pathways (ERP). This study aimed to assess compliance to ERP-set early re-alimentation policy and to compare outcomes of early fed patients and patients in whom early feeding was withhold due to the independent decision making of the surgeon. For this purpose, demographic, surgical and outcome data of all consecutive elective colorectal surgical procedures (2011–2016) were retrieved from a prospectively maintained institutional ERP database. The primary endpoint was postoperative ileus (POI). Surgical 30-day outcome and length of stay were compared between patients undergoing the pathway-intended early re-alimentation pattern and patients in whom early re-alimentation was not compliant. Out of the 7103 patients included, 1241 (17.4%) were not compliant with ERP re-alimentation. Patients with delayed re-alimentation presented with more postoperative complications (37 vs. 21%, p < 0.001) and a prolonged length of hospital stay (8 ± 7 vs. 5 ± 4 days, p < 0.001). While male gender (odds ratio (OR) 1.24; 95% confidence interval (CI) 1.04–1.32), fluid overload (OR 1.38; 95% CI 1.16–1.65) and high American Society of Anaesthesiologists (ASA) score (OR 1.51; 95% CI 1.27–1.8) were independent risk factors for POI, laparoscopy (OR 0.51; 95% CI 0.38–0.68) and ERP compliant diet (OR 0.46; 95% CI 0.36–0.6) were both protective. Hence, this study provides further evidence of the beneficial effect of early oral feeding after colorectal surgery.

Abstract Background This is the fourth updated Enhanced Recovery After Surgery (ERAS ® ) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS ® protocol. Methods A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta‐analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Results All recommendations on ERAS ® protocol items are based on best available evidence; good‐quality trials; meta‐analyses of good‐quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly. Conclusions The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS ® Society in this comprehensive consensus review.