The Incidence of Prolonged Postoperative Ileus After Laparoscopic Colorectal Surgery—Does ERAS Protocol Bring Anything New?

A substantial percentage of patients undergoing colorectal surgery develop prolonged postoperative ileus (PPOI). Since the data on its incidence and risk factors in patients undergoing laparoscopic colorectal surgery with ERAS protocol are sparse, we aimed to analyse them in a group of 295 consecutive patients operated on laparoscopically for colorectal cancer. The study was a prospective observation of 295 patients. In all of them, the 16-item ERAS protocol was applied. The primary outcome was the occurrence of PPOI. Secondary outcomes were risk factors of PPOI. PPOI incidence rate was 9.8%. In 8 (27.6% of PPOI group) patients, it was secondary to other underlying complication. In the remaining 21 (72.4% of PPOI group) cases, it was primary. In 80.9% cases, it resolved completely by five postoperative days. Using univariate regression analysis, we observed that only the female sex (OR 2.71) was an independent predictor of PPOI development, whereas age >65 years was associated with a lower risk (OR 0.33). Also patients after procedures involving handling the small bowel were more likely to develop PPOI (OR 2.65). The remaining demographic and perioperative parameters were not statistically significant. The incidence of PPOI in patients after laparoscopy with ERAS protocol is low and usually resolves within 5 days. However, longer PPOI may indicate underlying complications. Traditional risk factors for PPOI seem to play a limited role in its development.     

Spontaneous Retroperitoneal and Rectus Sheath Hemorrhage—Management,Risk Factors and Outcomes

World Journal of Surgery - Spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH) is associated with high mortality in the literature, but studies on the subject are lacking. The...     

Are Gender,Comorbidity, and Obesity Risk Factors for Postoperative Periprosthetic Fractures After Primary Total Hip Arthroplasty?

We studied the frequency and patient risk factors for postoperative periprosthetic fractures after primary total hip arthroplasty (THA). With a mean follow-up of 6.3 years, 305 postoperative periprosthetic fractures occurred in 14?065 primary THAs. In multivariable-adjusted Cox regression analyses, female gender (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.17-1.88), Deyo-Charlson comorbidity score of 2 (HR, 1.74 for score of 2; 95% CI, 1.25-2.43) or 3 or higher (HR, 1.71; 95% CI, 1.26-2.32), and American Society of Anesthesiologist class of 2 (HR, 1.84; 95% CI, 0.90-3.76) or 3 (HR, 2.45; 95% CI, 1.18-5.1) or 4 or higher (HR, 2.68; 95% CI, 0.70-10.28) were significantly associated with higher risk/hazard, and cemented implant, with lower hazard (HR, 0.68; 95% CI, 0.54-0.87) of postoperative periprosthetic fractures. Interventions targeted at optimizing comorbidity management may decrease postoperative fractures after THA.     

Who Is at Risk for Postdischarge Nausea and Vomiting after Ambulatory Surgery?

BACKGROUND:: About one in four patients suffers from postoperative nausea and vomiting. Fortunately, risk scores have been developed to better manage this outcome in hospitalized patients, but there is currently no risk score for postdischarge nausea and vomiting (PDNV) in ambulatory surgical patients. METHODS:: We conducted a prospective multicenter study of 2,170 adults undergoing general anesthesia at ambulatory surgery centers in the United States from 2007 to 2008. PDNV was assessed from discharge until the end of the second postoperative day. Logistic regression analysis was applied to a development dataset and the area under the receiver operating characteristic curve was calculated in a validation dataset. RESULTS:: The overall incidence of PDNV was 37%. Logistic regression analysis of the development dataset (n = 1,913) identified five independent predictors (odds ratio; 95% CI): female gender (1.54; 1.22 to 1.94), age less than 50 yr (2.17; 1.75 to 2.69), history of nausea and/or vomiting after previous anesthesia (1.50; 1.19 to 1.88), opioid administration in the postanesthesia care unit (1.93; 1.53 to 2.43), and nausea in the postanesthesia care unit (3.14; 2.44-4.04). In the validation dataset (n = 257), zero, one, two, three, four, and five of these factors were associated with a PDNV incidence of 7%, 20%, 28%, 53%, 60%, and 89%, respectively, and an area under the receiver operating characteristic curve of 0.72 (0.69 to 0.73). CONCLUSIONS:: PDNV affects a substantial number of patients after ambulatory surgery. We developed and validated a simplified risk score to identify patients who would benefit from long-acting prophylactic antiemetics at discharge from the ambulatory care center.     

Bariatric Surgery versus Lifestyle Interventions for Morbid Obesity—Changes in Body Weight,Risk Factors and Comorbidities at 1 Year

Background  

Few studies have looked at non-surgical alternatives for morbid obese patients. This study aims to compare 1-year weight loss and changes in risk factors and comorbidities after bariatric surgery and three conservative treatments.     

What Are the Risk Factors and Complications Associated With Intraoperative and Postoperative Fractures in Total Wrist Arthroplasty?

Background

Total wrist arthroplasty (TWA) can relieve pain and preserve some wrist motion in patients with advanced wrist arthritis. However, few studies have evaluated the risks and outcomes associated with periprosthetic fractures around TWAs.

Questions/purposes

(1) What is the risk of intraoperative and postoperative fractures after TWAs? (2) What factors are associated with increased risk of intraoperative and postoperative fracture after TWAs? (3) What is the fracture-free and revision-free survivorship of TWAs among patients who sustained an intraoperative fracture during the index TWA?

Methods

At one institution during a 40-year period, 445 patients underwent primary TWAs. Of those, 15 patients died before 2 years and 5 were lost to followup, leaving 425 patients who underwent primary TWAs with a minimum of 2-year followup. The primary diagnosis for the TWA included osteoarthritis ([OA] 5%), inflammatory arthritis (90%), and posttraumatic arthritis (5%). Indications for TWA included pancarpal arthritis combined with marked pain and loss of wrist function. The mean age of the patients was 57 years, BMI was 26 kg/m², and 73% were females. Six different implants were used during the 40-year period. Mean followup was 10 years (range, 2–18 years).

Results

Intraoperative fractures occurred in nine (2%) primary TWAs, while postoperative fractures occurred after eight (2%) TWAs. After analyzing demographics, comorbidities, and surgical factors, intraoperative fractures were found to be associated with only age at surgery (hazard ratio [HR], 1.10; 95% CI, 1.03–1.20; p = 0.006) and use of a bone graft (HR, 5.80; 95% CI, 1.18–23.08; p = 0.03). No factors were found to be associated with increased risk of postoperative fractures; specifically, intraoperative fracture was not associated with subsequent fracture development. The 5-, 10-, and 15-year Kaplan–Meier survival rates free of postoperative fracture were 99%, 98%, and 95%, respectively. The 5- and 10-year revision-free survival rates after intraoperative fracture were 88% and 88%, respectively, compared with 84% and 74% without an intraoperative fracture (p = 0.36). Furthermore, the survival-free of revision surgery rates for aseptic distal loosening at 5 and 10 years were 88% and 88%, respectively, compared with 93% and 87% without a fracture (p = 0.85).

Conclusions

Intraoperative fractures occur in approximately 2% of TWAs. These fractures do not appear to affect long-term implant survival or risk of fracture. Patient age and the need for bone graft were the only factors in the risk of intraoperative fractures. Postoperative fractures also occur in 2% of TWAs, but often result in revision surgery.

Level of Evidence

Level III, therapeutic study.

     

ASO Visual Abstract: Cancer-Related Fatigue after Esophageal Cancer Surgery—Impact of Postoperative Complications

Annals of Surgical Oncology -     

Systematic Review of Obesity Surgery Mortality Risk Score—Preoperative Risk Stratification in Bariatric Surgery

Bariatric surgery is the best long term treatment for morbid obesity. However, it carries risks of considerable morbidity and potential mortality. There is no published review on pre-operative identification of high-risk patients in bariatric surgery. This systematic review analyses obesity surgery mortality risk score (OS-MRS) as a tool for pre-operative prediction of mortality risk in bariatric surgery. Medline and Embase was systematically searched using the medical subjects headings (MeSH) terms 'bariatric surgery' and 'mortality' with further free text search and cross references. Studies that described OS-MRS to predict mortality risk after bariatric surgery were included in this review. Six studies evaluated 9,382 patients to assess the validity of OS-MRS to predict the mortality risk after bariatric surgery. Patient's age ranged from 19 to 67 years, and the body mass index ranged from 30 to 84. There were 83 deaths among the 9,382 patients (0.88 %) with individual studies reporting a mortality range from 0 % to 1.49 %. There were 13 deaths among 4,912 (0.26 %) class A patients, 55 deaths among 4,124 (1.33 %) class B patients and 15 deaths among 346 (4.34 %) class C patients. Mortality in classes A, B and C was significantly different from each of the other two classes (P < 0.05, χ(2)). This systematic review confirms that OS-MRS stratifies the mortality risk in the three-risk classification subgroups of patients. The OS-MRS can be used for pre-operative identification of high-risk patients undergoing primary Roux-en-Y gastric bypass surgery.     

NAFLD and Insulin Resistance Do Not Increase the Risk of Postoperative Complications Among Patients Undergoing Bariatric Surgery—A Prospective Analysis

Background  

Nonalcoholic fatty liver disease (NAFLD) and insulin resistance are common consequences of obesity and are highly prevalent among patients undergoing bariatric surgery. Insulin resistance and NAFLD have been reported to be associated with postoperative complications following major surgery.     

Pre-operative Predictors of Weight Loss at 1-Year after Lap-Band® Surgery

Background: The authors studied a range of preoperative factors for their predictive value of effectivenes of Lap-Band? placement, using the percentage of excess weight loss at 1-year as the outcome measure (%EWL1). Methods: All factors were measured and recorded prior to surgery. Factors included: patient demographics, family, medical and weight history. Laboratory measures and the responses to the SF36 Health Survey were also assessed. Factors were assessed for correlation with %EWL1. Results: The group (N=440, F:M 383:57) had mean age 40.0 ± 9.5 years, weight of 126 ± 25 kg, and BMI 45.6 ± 7.5 kg/m2 pre-operatively. At 1-year follow-up, the group had mean weight 97.6 ± 20 kg, BMI 35.6 ± 6.3 kg/m2, and %EWL1 45.8 ± 17%. Increasing age (R=-0.13, p<0.01) and preoperative BMI (R=-0.22, p<0.001) were significantly associated with less %EWL1 and all other factors were controlled for these before assessing significance. Important factors associated with a lower %EWL1 included: hyperinsulinemia (R=-0.36, p<0.001), insulin resistance (R=-0.33, p<0.001) and disease associated with insulin resistance, poor physical ability, pain, and poor general health responses to the SF-36 Health Survey. Patients who consumed alcohol regularly had a better rate of weight loss (R= 0.23, p<0.005). Factors that had no influence included gender, a history of mental illness and measures of mental health, previous bariatric surgery, and a history of many medical conditions associated with obesity. Conclusion: Important physical factors have been found to influence the rate of weight loss.Those with increased age, pain, physical disability and insulin resistance have a great deal to gain from weight loss. Although this study has identified factors that are associated with less weight loss, we have not found any factor that predicts an unacceptably low weight loss and thus provides a contraindication to Lap-Band? placement. The findings of this study allow us to set more realistic goals for the rate of weight loss in specified sub-groups of our patients.     

Risk Factors and True Incidence of Pouchitis in Patients after Ileal Pouch–Anal Anastomoses

Total colectomy, mucosal proctectomy, and ileal J pouch–anal anastomosis (IPAA) has become the procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis. The purpose of this study was to determine the short- and long-term outcomes of patients undergoing IPAA by a single surgeon, correlating intraoperative technical aspects with outcomes, and to characterize better the clinical syndrome of pouchitis. A retrospective review was performed of 114 consecutive patients who underwent IPAA by a single surgeon between December 1987 and August 1996. Clinical follow-up and operative notes were reviewed, and patient questionnaires were obtained for all patients. The mean follow-up was 3 years (range 0.5–8.0 years). The average age of the patients was 39 years (range 16–72 years). There were 64 males and 50 females. Indications for operation were ulcerative colitis (n= 101) and familial polyposis coli (n= 13). Long-term morbidity occurred in 41% of patients (small bowel obstruction 10%, anastomotic stricture 9%). Pouch excision was required in only three patients. Stool frequency (mean ± SE) was 6.1 ± 0.2 and did not change with duration of follow-up. Only 7% of patients reported fecal soilage. The incidence of pouchitis was 59% (n= 67), with 4.2 ± 0.3 episodes of pouchitis per patient. Using multivariate analysis, the factors significantly associated with the incidence of pouchitis were gender (p= 0.008) and duration of follow-up (p= 0.02). A total of 37 of 50 women (74%) but only 30 of 64 men (47%) developed pouchitis. The incidence of pouchitis increased with the duration of follow-up. The incidences of pouchitis in patients followed for 6 months, 1 year, and 3 years were 25%, 37%, and 50%, respectively. Of patients followed more than 6 years, the incidence of pouchitis was 94% (15/16). There was not a significant correlation between anastomotic tension or the extent of arterial dissection of the ileal mesentery required to achieve IPAA and the incidence of pouchitis. The best antibiotics for pouchitis were metronidazole (54% of patients) and ciprofloxacin (37%). Eleven patients have required nearly continuous antibiotics. Patient satisfaction with the outcome is high, with a mean satisfaction of 8.4 (0, dissatisfied; 10, extremely satisfied). This review demonstrates a high incidence of pouchitis in patients after IPAA, which is due to the more liberal definition of the syndrome and the complete follow-up achieved in this report compared to previous series. This study also is unique in identifying the significantly higher incidence of pouchitis in women, although the overall satisfaction with the clinical outcome in patients undergoing IPAA remains high.