The effect of intraoperative goal-directed hemodynamic therapy on volume status, venous congestion, and ventricular function in elective colorectal surgery: an observational pilot study using point-of-care ultrasound

There is continued controversy regarding the benefits of goal-directed fluid therapy, with earlier studies showing marked improvement in morbidity and length-of-stay that have not been replicated more recently. The aim of this study was to compare patient outcomes in elective colorectal surgery patients having goal-directed versus restrictive fluid therapy. Inclusion criteria included suitability for an Enhanced Recovery After Surgery care pathway and patients with an American Society of Anesthesiologists Physical Status score of 1 to 3. Patients were intraoperatively randomised to either restrictive or Doppler-guided goal-directed fluid therapy. The primary outcome was length-of-stay; secondary outcomes included complication rate, change in haemodynamic variables and fluid volumes. Compared to restrictive therapy, goal-directed therapy resulted in a greater volume of intraoperative fluid, 2115 (interquartile range 1350 to 2560) ml versus 1500 (1200 to 2000) ml, P=0.008, and was associated with an increase in Doppler-derived stroke volume index from beginning to end of surgery, 43.7 (16.3) to 54.2 (21.1) ml/m(2), P <0.001, in the latter group. Length-of-stay was similar, 6.5 (5 to 9) versus 6 (4 to 9) days, P=0.421. The number of patients with any complication (minor or major) was similar; 0% (30) versus 52% (26), P=0.42, or major complications, 1 (2%) versus 4 (8%), P=0.36, respectively. The increased perioperative fluid volumes and increased stroke volumes at the end of surgery in patients receiving goal-directed therapy did not translate to a significant difference in length-of-stay and we did not observe a difference in the number of patients experiencing minor or major complications.

Purpose: The use of prophylactic antibiotics in elective colorectal surgery is essential. Although postoperative prophylactic antibiotics are recommended within 24 hr, the optimal duration of the use of prophylactic antibiotics after colorectal surgery has not yet been fully proven in Korea. The aim of this study was to compare infectious outcomes in elective colorectal cancer surgery between postoperative 3-day antibiotic therapy and 5-day therapy. Methods: We conducted a multicenter, randomized trial of a 3-day use vs. a 5-day use of the second-generation cephalosporin cefotetan after elective colorectal surgery. The main outcome measures were the incidences of surgical site infection and all other infectious complications within 21 days after surgery. Results: A total of 306 patients were enrolled. Fifty-one patients were excluded because they received additional surgery or dropped out during the study. Two-hundred fifty-five patients were analyzed in this study. The two groups were similar in terms of demographics, ASA score, tumor location, tumor stage, surgical approach (conventional open vs. laparoscopy-assisted vs. robotic-assisted), and type of operation. The incidences of surgical site infection were not significantly different between the 3-day use group (4/130 or 3.1%) and the 5-day use group (3/125 or 2.4%) (P=1.000). Incidences of overall infectious diseases did not differ significantly between the two groups. Postoperatively, both groups had similar values in their white blood cell count, absolute neutrophil count, and C-reactive protein levels. However, the number of patients is small to draw a definite conclusion in this study. Conclusion: Three-day cefotetan administration may be not inferior in preventing surgical site infection compared to 5-day antibiotic administration. However, further studies with a large number of patients are needed before a definite conclusion can be drawn.

Postoperative delirium in elderly after elective and acute colorectal surgery: A prospective cohort study

The clinical significance of early ostomy complications has been emphasized worldwide, and the current evidence concerning the impact of emergency or elective surgery on ostomy complications is limited. This study aimed to investigate the effect of elective and emergency colorectal surgery on early ostomy complications and the risk factors associated with specific complications. A mandatory colorectal recording system for consecutive ostomy patients between 2012 and 2020 was reviewed retrospectively. Patient socio-demographics, ostomy-related variables, and early period ostomy complications were retrieved from the patient records. The chi-square test, t-test, analysis of variance (ANOVA), and logistic regression were used to analyze the data. The study cohort included 872 patients. At least one or more complications developed in 573 (65.7%) patients, 356 (63.6%) in the emergency group, and 217 (69.6%) in the elective group. When comparing emergency surgery to elective surgery, necrosis (7.4% versus 3.4%, p = 0.009), mucocutaneous separation (37.2% versus 27.1%, p = 0.002), and bleeding (6.1% versus 2.1%, p = 0.003) were more prevalent. Peristomal irritant contact dermatitis (PICD) (37.3% versus 26%, p < 0.001) was more common in elective surgery. Risk factors for PICD were comorbidity (p = 0.003), malignant disease (p = 0.047), and loop ostomy (p < 0.001) in elective surgery; female sex (p = 0.025), neo-adjuvant therapy (p = 0.024), and ileostomy (p = 0.006) in emergency surgery. The height of the ostomy (less than 10 mm) was a modifiable risk factor for mucocutaneous separation in both elective surgery (p < 0.001) and emergency surgery (p = 0.045). Early ostomy complications were more likely to occur after emergency colorectal surgery than in an elective setting. Patient- and ostomy-related risk factors for complications differed between elective and emergency surgeries.

Increasing Differences in Surgical Site Infections After Emergency and Elective Colorectal Surgery.

Reply from the authors

BACKGROUND: Despite their higher incidence of colorectal cancer, ethnoracial minority and low-income patients have reduced access to elective colorectal cancer surgery. Although the Affordable Care Act’s Medicaid expansion increased screening colonoscopies, its effect on disparities in elective colorectal cancer surgery remains unknown. OBJECTIVE: This study assessed the effects of Medicaid expansion on elective colorectal cancer surgery rates overall and by race-ethnicity and income. DESIGN: Using the 2012-2015 State Inpatient Databases, a retrospective cohort study was conducted. SETTINGS: State Inpatient Databases from three expansion (Maryland, New Jersey, Kentucky) and two non-expansion states (Florida, North Carolina) were used. PATIENTS: This study examined 22,304 adult patients aged 18-64 who underwent colorectal cancer surgery. MAIN OUTCOME: Using interrupted time series analysis, the effect of Medicaid expansion on the odds of elective colorectal cancer surgery was assessed. RESULTS: Elective vs. non-elective surgery rates remained unchanged overall (70.2% vs 70.7%, p = 0.63) and in ethnoracial minorities in expansion states (whites from 72.8% to 73.8% pre to post, p = 0.40 and non-white from 64.0% to 63.1% pre to post, p = 0.67). There was an instantaneous increase in odds of elective surgery in expansion vs. non-expansion states at policy implementation (adjusted OR 1.37, 95% CI, 1.05-1.79, p = 0.02), but it subsequently decreased (combined adjusted OR 0.95, 95% CI, 0.92-0.99, p = 0.03). Elective surgery rates were also unchanged among ethnoracial minorities (instantaneous changes in expansion states, combined effect 1.06; pre-trend 1.01 vs. post trend 0.98) and low-income persons in expansion states (pre trend 1.03 vs. post-trend 0.97) (for all, p > 0.1). LIMITATIONS: The study was limited to 5 states. While patients may have increased access to cancer screening services and surgery post-expansion, the State Inpatient Database only provides information on patients who underwent surgery. CONCLUSIONS: Despite gains in screening, Medicaid expansion was not associated with reductions in known ethnoracial or income-based disparities in elective colorectal cancer surgery rates. Expanding access to colorectal cancer surgery for underserved populations likely requires attention to provider and health system factors contributing to persistent disparities.

Femoral Vein Pulsatility: What Does It Mean?

Postoperative Critical Care Admission Was Not Associated with Improved Postoperative Outcomes in Elective Colorectal Surgery: Secondary Analysis Of POWER Trial

Introduction: The cleansing of intestinal contents, were considered the mostimportant factor in the prevention of complications by most of the surgeons. While morbidityand mortality have been a matter of main concern in colorectal surgery during the past severaldecades. Despite these drawbacks mechanical bowel preparation is till practiced by most ofthe colorectal surgeons worldwide in elective colorectal surgery. So the aims of this study wereto find out the frequencies of wound infections, hospital stay, anastomotic leak and wounddehiscence’s in patients of two cohorts underwent elective colorectal surgery. Study Design:Prospective randomized control trial (RCT) study after having informed consent of participationas per described policy. Setting: Surgical Unit – I of People’s University of Medical and HealthSciences Nawabshah. Period: January 2012 to March 2016. Methods: 112 patients of bothgenders from 20-65 years in age, who underwent for Elective open colorectal surgery. In MBP,Sulphate and electrolyte free 136gm of polyethylence glycol (PEG) / two sachets with three litersof water were begun over 12 to 16 hours, the day before surgery in cohorts A only. Results:Regarding outcomes, wound infections were 12.5% and 16% in group A &amp; B respectively. Therewas no remarkable difference in post-operative length of hospital stay with mean stay of 8+2and 9+2 in group A &amp; B respectively. While disruption of anastomosis were 5.3% and 9% ingroup A &amp; B respectively, while the frequency of incisional hernia was same in both groups.Conclusion: There is no benefit of enduring MBP in Elective Colorectal Surgery and can safelybe performed without it.

Anemia is highly prevalent in the colorectal surgery population, affecting 30-70% of patients. Anemia is associated with significant morbidity and mortality; however, there is a lack of evidence on how much anemia impacts healthcare costs. This study aims to determine the hospital cost of index surgical admission, postoperative length of stay, and transfusion rate associated with preoperative anemia in elective major colorectal surgery. This historical cohort study included 851 adult inpatients having elective colorectal surgery at a tertiary care academic health sciences network between April 2010 and February 2016. Anemia was defined as hematocrit ≤ 39%. The primary outcome was total hospital costs standardized to 2016 CAD. Secondary outcomes were postoperative length of stay and transfusion. Multivariable regression analyses and propensity score methods were used to measure adjusted associations between anemia and outcomes. Before surgery, 381/851 (45%) patients were anemic. The mean (standard deviation [SD]) cost of index admission for an elective colorectal surgery was 20,040 (23,219) CAD. Anemia was associated with an adjusted 14% relative increase in costs (95% confidence interval [CI], 6 to 23; P<0.001). The total hospitalization cost attributable to anemia was 3,027 CAD (95% CI, 2,670 to 3,388). Hospital costs and length of stay were highly associated; anemia was associated with an 18% increase in length of stay (95% CI, 7 to 30; P<0.001) and increased transfusion rates (risk ratio, 4.7; 95% CI, 2.71 to 8.33; P<0.001). Over 2,600 CAD per index surgical admission is attributable to preoperative anemia. Preoperative interventions with per patient cost of less than 2,600 CAD could be cost effective at the hospital level. www.clinicaltrials.gov (NCT03476707); registered 26 March, 2018.

American College of Surgeons NSQIP Risk Calculator Accuracy for Emergent and Elective Colorectal Operations

The World Health Organization recommends hyperoxia (80% fraction of inspired oxygen, FiO2) during and for 2-6 hours following surgery to reduce surgical site infection (SSI). However, some studies suggest increased cardiovascular complications with such a high perioperative FiO2. The goal of our study was to compare the appearance of cardiovascular complications in elective adult colorectal surgery comparing the use of FiO2>0.8 versus conventional therapy (FiO2<0.4). We performed a randomized controlled trial in intubated patients undergoing elective major colorectal surgery. Patients were randomly assigned to receive perioperative FiO2>0.8 or FiO2<0.4. The primary outcome, expressed as Odds Ratio (OR) ±95% Confidence Interval (95%CI), was the incidence of MINS (myocardial injury after noncardiac surgery evaluated for the first 4 postoperative days). Secondary outcomes included MACCE (major adverse cardiovascular and cerebral events) up to 30 postoperative days, SSI, other postoperative complications (according to Clavien-Dindo classification) and length of stay. We included in the final analyses 403 patients. Comparing the FiO2>0.8 and FiO2<0.4 groups, there was no difference in the appearance of MINS (6.0% vs. 10.4%; OR 0.55; 95% CI: 0.26-1.14; P=0.945). There were no differences between the groups for important secondary outcomes including MACCE to 30 days, SSI, postoperative complications or length of stay. Perioperative hyperoxia therapy (FiO2>0.8) with the aim of decreasing SSI did not increase cardiovascular complications after elective colorectal surgery in a general population.

Surgical site infection (SSI) and anastomotic leak (AL) are major contributors to postoperative morbidity in elective colorectal surgery. Although the addition of oral antibiotics (oAB) to mechanical bowel preparation (MBP) is recommended by several professional societies, uncertainty remains about its effectiveness and hence uptake globally is inconsistent, particularly in patients undergoing surgery for colorectal cancer (CRC). We conducted a systematic review and meta-analysis (PROSPERO CRD420251055720) of randomised controlled trials comparing MBP plus oAB with MBP alone in adult patients undergoing elective colorectal cancer resection. The primary outcomes were overall SSI. Secondary outcomes included CDC-defined SSI subtypes, AL and Clostridium difficile infection. A prespecified subgroup analysis was performed for trials limited to rectal cancer resections. Risk of bias was assessed using the RoB 2.0 tool, and the certainty of evidence was evaluated with GRADE methodology. Nine trials comprising 3046 patients with colorectal cancer met inclusion criteria. Compared with MBP alone, the addition of oAB significantly reduced the risk of SSI (RR: 0.55, 95% CI: 0.44-0.68; I2 = 8%; p < 0.001) and AL (OR: 0.45, 95% CI: 0.32-0.65; I2 = 0%; p < 0.001). This benefit persisted across CDC-defined superficial incisional (RR: 0.53, 95% CI: 0.34-0.82; p = 0.005), deep incisional (RR: 0.40, 95% CI: 0.22-0.71; p = 0.002) and organ/space infections (RR: 0.55, 95% CI: 0.39-0.78; p < 0.001). In rectal cancer patients (n = 1172), the pooled risk of SSI remained lower with MBP plus oAB (RR: 0.48, 95% CI: 0.29-0.79; I2 = 41%; p = 0.004) and AL (OR: 0.40, 95% CI: 0.25-0.65; I2 = 0%; p < 0.001). Sensitivity analyses confirmed the robustness of these findings. The certainty of evidence was rated as moderate to high for all primary outcomes. The addition of oral antibiotics to mechanical bowel preparation significantly reduces the risk of SSI and anastomotic leak in elective colorectal cancer surgery. The benefits are consistent in rectal cancer-specific cohorts, supporting the integration of oral antibiotics into standard bowel preparation protocols for patients undergoing colorectal cancer resection.

Rising health care costs necessitate a reassessment of routine preoperative practices. Despite low transfusion rates in elective colorectal operations, many hospitals continue to perform routine preoperative type and screen testing. To assess perioperative blood transfusion rates and determine preoperative and surgical factors associated with transfusions to determine whether the routine preoperative type and screen testing are necessary for elective abdominal colorectal surgeries, particularly in the setting of minimally invasive surgery. Retrospective cohort study. Mayo Clinic, 2019-2023. Adult patients undergoing elective abdominal colorectal operations. Exclusion criteria included emergent operations and nonabdominal procedures. None. The primary outcome was the incidence of intraoperative and immediate postoperative (≤72 hours) blood product transfusion. Secondary outcomes assessed associations between transfusion rates, surgical approach, and preoperative variables. Among 4652 patients, 2770 underwent minimally invasive surgery and 1882 underwent open procedures. Perioperative red blood cell transfusion rates were lower in minimally invasive procedures (3.0% colectomy, 4.5% proctectomy) compared to open procedures (8.7% colectomy, 21.5% proctectomy). Open proctectomy was the strongest predictor of transfusion (OR 12.05; 95% CI, 8.94-16.26; p < 0.0001) followed by open colectomy (OR 2.59; 95% CI, 2.04-3.30; p < 0.0001). Preoperative factors including ASA class IV (OR 5.21; 95% CI, 1.09-24.82; p < 0.0382) and anemia (OR 4.14; 95% CI, 3.09-5.55; p < 0.0001) were also significantly associated with red blood cell transfusion. The retrospective nature of the study may introduce selection bias. In addition, institutional practice patterns may limit the generalizability of findings. Patients undergoing elective minimally invasive colorectal surgery have very low rates of perioperative blood transfusions; thus, routine preoperative type and screen testing is likely unnecessary for this patient cohort. However, patients undergoing planned open operations, likely due to procedural complexity, and those who are ASA class IV, have preoperative anemia, or have anal cancer have higher transfusion risks and may benefit from selective testing. Implementing a risk-stratified approach based on surgical technique and patient comorbidities could potentially reduce unnecessary testing and associated health care costs. See Video Abstract . ANTECEDENTES:El aumento en los costos de la atención médica exigen la reevaluación de las practicas preoperatorias de rutina. A pesar de las bajas tasas de transfusión en la cirugía colorrectal electiva, muchos hospitales continúan realizando pruebas de tipo y de cribado preoperatorios de forma rutinaria. El poresente estudio evalúa las tasas de transfusiones sanguíneas perioperatorias e identifica los factores asociados con éstas transfusiones para determinar la necesidad de pruebas de tipo y de cribado preoperatorios de forma rutinaria en cirugías colorrectales abdominales electivas.OBJETIVO:Evaluar las tasas de transfusión sanguínea perioperatoria y determinar los factores preoperatorios y quirúrgicos asociados con las transfusiones, con el fin de determinar si las pruebas de tipo y de cribado preoperatorias de forma rutinaria son necesarias en cirugías colorrectales abdominales electivas, en particular en el contexto de la cirugía mínimamente invasiva.DISEÑO:Estudio de cohortes retrospectivo.ESCENARIO:Clínica Mayo, 2019-2023.PACIENTES:Pacientes adultos sometidos a cirugías colorrectales abdominales electivas. Los criterios de exclusión incluyeron operaciones de emergencia y procedimientos no abdominales.INTERVENCIONES:Ninguna.PRINCIPALES MEDIDAS DE RESULTADOS:El resultado primario fue la incidencia de transfusión de hemoderivados intraoperatoriamente y postoperatoria inmediata (≤72 horas). Los resultados secundarios evaluaron la asociación entre las tasas de transfusión, el abordaje quirúrgico y las variables preoperatorias.RESULTADOS:De 4652 pacientes, 2770 se sometieron a cirugía mínimamente invasiva y 1882 a laparotomía. Las tasas de transfusión eritrocitaria perioperatoria fueron menores en los procedimientos mínimamente invasivos (3,0 % colectomía, 4,5 % proctectomía) que en los procedimientos abiertos (8,7 % colectomía, 21,5 % proctectomía). La proctectomía abierta fue el predictor más sólido de transfusión (OR: 12,05; IC del 95 %: 8,94-16,26; p < 0,0001), seguida de la colectomía abierta (OR: 2,59; IC del 95 %: 2,04-3,30; p < 0,0001). Los factores preoperatorios, incluyendo la clase ASA IV (OR 5,21; IC del 95 %: 1,09-24,82; p < 0,0382) y la anemia (OR 4,14; IC del 95 %: 3,09-5,55; p < 0,0001), también se asociaron significativamente con la transfusión de glóbulos rojos.LIMITACIONES:La naturaleza retrospectiva del estudio puede introducir sesgo de selección. Además, los patrones de práctica institucional pueden limitar la generalización de los hallazgos.CONCLUSIONES:Los pacientes sometidos a cirugía colorrectal mínimamente invasiva electiva tienen tasas muy bajas de transfusiones sanguíneas perioperatorias, por lo que las pruebas de detección y tipo de sangre preoperatorias de rutina probablemente sean innecesarias para esta cohorte de pacientes. Sin embargo, los pacientes sometidos a cirugías abiertas planificadas, probablemente debido a la complejidad del procedimiento, y aquellos con clase ASA IV, anemia preoperatoria o cáncer anal, tienen mayor riesgo de transfusión y podrían beneficiarse de pruebas selectivas. La implementación de un enfoque estratificado por riesgo basado en la técnica quirúrgica y las comorbilidades del paciente puede reducir las pruebas innecesarias y los costos de atención médica asociados. (Traducción-Dr. Xavier Delgadillo ).