Elective Open Colorectal Surgery Research Articles

The effect of anesthesia on the magnitude of the postoperative systemic inflammatory response in patients undergoing elective surgery for colorectal cancer in the context of an enhanced recovery pathway: A prospective cohort study.

There are reports that the use of regional anesthesia (RA) may be associated with better perioperative surgical stress response in cancer patients compared with general anesthetics (GA). However, the role of anesthesia on the magnitude of the postoperative systemic inflammatory response (SIR) in colorectal cancer patients, within an enhanced recovery pathway (ERP), is not clear.The aim of the present study was to examine the effect of anesthesia, within an enhanced recovery pathway, on the magnitude of the postoperative SIR in patients undergoing elective surgery for colorectal cancer.Database of 507 patients who underwent elective open or laparoscopic colorectal cancer surgery between 2015 and 2019 at a single center was studied. The anesthetic technique used was categorized into either GA or GA + RA using a prospective proforma. The relationship between each anesthetic technique and perioperative clinicopathological characteristics was examined using binary logistic regression analysis.The majority of patients were male (54%), younger than 65 years (41%), either normal or overweight (64%), and were nonsmokers (47%). Also, the majority of patients underwent open surgery (60%) and received mainly general + regional anesthetic technique (80%). On univariate analysis, GA + RA was associated with a lower day 4 CRP (≤150/>150 mg/L) concentration. On day 4, postoperative CRP was associated with anesthetic technique [odds ratio (OR) 0.58; confidence interval (CI) 0.31–1.07; P = .086], age (OR 0.70; CI 0.50–0.98; P = .043), sex (OR 1.15; CI 0.95–2.52; P = .074), smoking (OR 1.57; CI 1.13–2.19; P = .006), preoperative mGPS (OR 1.55; CI 1.15–2.10; P = .004), and preoperative dexamethasone (OR 0.70; CI 0.47–1.03; P = .072). On multivariate analysis, day 4 postoperative CRP was independently associated with anesthetic technique (OR 0.56; CI 0.32–0.97; P = .039), age (OR 0.74; CI 0.55–0.99; P = .045), smoking (OR 1.58; CI 1.18–2.12; P = .002), preoperative mGPS (OR 1.41; CI 1.08–1.84; P = .012), and preoperative dexamethasone (OR 0.68; CI 0.50–0.92; P = .014).There was a modest but an independent association between RA and a lower magnitude of the postoperative SIR. Future work is warranted with multicenter RCT to precisely clarify the relationship between anesthesia and the magnitude of the postoperative SIR.

Enhanced recovery program versus traditional postoperative care for elective open colorectal cancer surgery

Background Traditional colorectal surgeries usually require a relatively long hospital stay of ∼10 days. Inadequate pain control, intestinal dysfunction, and immobilization are the main factors associated with delay in recovery. Enhanced recovery protocols have been used to optimize the perioperative care. Objectives To study the outcome of the enhanced recovery program for selected patients with colorectal malignancies subjected to elective surgery compared with similar patients subjected to surgery with traditional perioperative care. Patients and methods This prospective study was performed at Fayoum University Hospital from April 2008 to June 2017 and involved 97 patients who had uncomplicated colorectal cancer and were planned for elective open colorectal surgeries. They were divided into two groups: group A (44 patients) was subjected to surgery based on fast-track protocol and group B (53 patients) was subjected to surgery based on traditional perioperative care. Hospital stay, perioperative morbidity, mortality data, postoperative pain, and patient satisfaction data were collected, statistically analyzed, and recorded. Results In groups A and B, respectively, the mean±SD age was 47.3±5.1 and 43.7±6.1 years, the number of males was 31 and 44, whereas the number of females was 13 and nine. According to American Society of Anesthesiologists (ASA) score, 43.2 and 54.7% of patients were ASA I and 56.8 and 45.3% were ASA II in groups A and B, respectively. Overall, 40.9 and 43.4% underwent low anterior resection, 36.4 and 22.6% sigmoidectomy, 22.7 and 28.3% right colectomy, and 0 and 5.7% left colectomy in groups A and B, respectively. The mean±SD length of postoperative hospital stay was 3.58±0.24 and 8.84±1.87 days in groups A and B, respectively. There was no mortality in the two groups, and overall morbidity rate was 22.7 and 22.6% in groups A and B, respectively. Overall, 4.5 and 7.5% had wound infection, 2.3 and 0% had abdominal wall dehiscence, 11.4 and 11.3% had persistent vomiting, 2.3 and 3.8% had postoperative fever in groups A and B, respectively. Moreover, one (2.3%) patient in group A required readmission and resurgery to manage anastomotic leakage and peritonitis. Conclusions Enhanced recovery program for elective colorectal cancer surgery has a very good effect on postoperative recovery, as it shortens the length of hospital stay, with high safety and good patient compliance; therefore, we strongly recommend the application of such protocols, provided the availability of well-trained and adequately experienced personnel in well-equipped centers.

Negative Pressure Wound Therapy Use to Decrease Surgical Nosocomial Events in Colorectal Resections (NEPTUNE): A Randomized Controlled Trial.

Determine if negative pressure wound therapy (NPWT) reduces surgical site infection (SSI) in primarily closed incision after open and laparoscopic-converted colorectal surgery. SSIs after colorectal surgery are a common cause of morbidity. The prophylactic effect of NPWT has not been established. We undertook this study to evaluate if, among patients undergoing open colorectal resection, NPWT, as compared with standard postoperative dressings, is associated with a reduction in the rate of postoperative SSI. In a randomized, controlled trial, 300 patients undergoing elective open colorectal surgery were assigned to receive prophylactic NPWT or standard gauze dressing. The primary end-point was 30-day SSI, as assessed by wound care experts blinded to treatment arm. Secondary outcomes included length of stay. Statistical analysis was performed on an intention-to-treat basis. A priori subgroup analysis was planned for patients who received a stoma at the time of initial operation. The incidence of SSI at 30-days postoperatively was no different between experimental and control groups (32% vs 34% respectively, P = 0.68). Length of stay was also no different at a median of 7 days (IQR 5) for both groups. Among patients receiving a stoma, there was also no difference in SSI between the experimental and control groups (38% vs 33% respectively, P = 0.66). Prophylactic use of NPWT on primarily closed incisions after open colorectal surgery was not associated with a decrease in SSI rate when compared with standard gauze dressing. Clinicaltrials.gov (NCT02007018).

Receiver operating characteristic analysis to determine optimal fluid management during open colorectal surgery.

The present study aimed to analyse fluid management and to define optimal fluid-related thresholds for elective open colorectal surgery. A retrospective analysis was made of all consecutive elective open colorectal resections performed in our tertiary centre between May 2011 and May 2017. The main outcomes were postoperative complications [overall (I-V) and severe (IIIB-V) according to the Clavien classification], respiratory complications and postoperative ileus (POI). Critical thresholds regarding perioperative fluid management and postoperative weight gain were identified by using receiver operator characteristic (ROC) analysis. Independent risk factors for overall complications were identified by multivariable logistic regression analysis. Of 121 patients who had open operations, 84 (69%) had some complication and 26 (21%) had severe complications. Respiratory complications and POI occurred in 15 (12%) and 46 patients (38%), respectively. The thresholds for intravenous fluids were 3.5l at postoperative day (POD) 0 [area under ROC curve (AUROC) 0.7 for any 0.69 for respiratory complications] and 3.5kg weight gain at POD 2 (AUROC 0.82 for respiratory complications). Multivariable analysis revealed weight gain of >3.5kg at POD 2 (OR 5.9; 95% CI 1.3-16.6) as a significant risk factor for overall complications. Acute kidney injury was observed in five patients (4%), three (5%) in the group with >3.5l at POD 0 and two (3%) in the group with <3.5l at POD 0 (P=0.64). Creatinine increase was transitory and all patients regained baseline levels before discharge. A weight gain of >3.5kg at POD 2 has been identified as the critical threshold for overall and respiratory complications and prolonged length of stay after open elective colorectal surgery.

Negative Pressure Wound Therapy Use to Decrease Surgical Nosocomial Events in Colorectal Resections (NEPTUNE): A Randomized Controlled Trial

Objective Determine if negative pressure wound therapy (NPWT) reduces surgical site infection (SSI) in primarily closed incision after open and laparoscopic-converted colorectal surgery. Background SSIs after colorectal surgery are a common cause of morbidity. The prophylactic effect of NPWT has not been established. We undertook this study to evaluate if, among patients undergoing open colorectal resection, NPWT, as compared with standard postoperative dressings, is associated with a reduction in the rate of postoperative SSI. Methods In a randomized, controlled trial, 300 patients undergoing elective open colorectal surgery were assigned to receive prophylactic NPWT or standard gauze dressing. The primary end-point was 30-day SSI, as assessed by wound care experts blinded to treatment arm. Secondary outcomes included length of stay. Statistical analysis was performed on an intention-to-treat basis. A priori subgroup analysis was planned for patients who received a stoma at the time of initial operation. Results The incidence of SSI at 30-days postoperatively was no different between experimental and control groups (32% vs 34% respectively, P = 0.68). Length of stay was also no different at a median of 7 days (IQR 5) for both groups. Among patients receiving a stoma, there was also no difference in SSI between the experimental and control groups (38% vs 33% respectively, P = 0.66). Conclusions Prophylactic use of NPWT on primarily closed incisions after open colorectal surgery was not associated with a decrease in SSI rate when compared with standard gauze dressing. Trial registration number Clinicaltrials.gov (NCT02007018).

Intravenous lidocaine infusions for 48 hours in open colorectal surgery: a prospective, randomized, double-blinded, placebo-controlled trial.

BackgroundAlthough intravenous (i.v.) lidocaine is used as a perioperative analgesic in abdominal surgery, evidence of efficacy is limited. The infusion dose and duration remain unclear. This study aimed to investigate the effect of a longer low-dose 48-hour infusion regimen on these outcomes.MethodsFifty-eight adults undergoing elective open colorectal surgery were randomized into the lidocaine group (1.5 mg/kg bolus followed by 1 mg/kg/h infusion for 48 hours) and control group. After surgery, patients were given a fentanyl patient-controlled analgesia machine and time to first bowel movement (primary outcome) and flatus were recorded. Postoperative pain scores and fentanyl consumption were assessed for 72 hours.ResultsThere was no significant difference in time to first bowel movement (80.1 ± 42.2 vs. 82.5 ± 40.4 hours; P = 0.830), time to first flatus (64.7 ± 38.5 vs. 70.0 ± 31.2 hours; P = 0.568), length of hospital stay (9 [8–13] vs. 11 [9–14) days; P = 0.531], nor postoperative pain scores in the lidocaine vs. control groups. Cumulative opioid consumption was significantly lower in the lidocaine vs. the control group from 24 hours onwards. At 72 hours, cumulative opioid consumption (µg fentanyl) in the lidocaine group (1,570 [825–3,587]) was over 40% lower than in the placebo group (2,730 [1,778–5,327]; P = 0.039).ConclusionsA 48-hour low-dose i.v. lidocaine infusion does not significantly speed the return of bowel function in patients undergoing elective open colorectal surgery. It was associated with reduced postoperative opioid consumption, but not with earlier hospital discharge, or lower pain scores.

Effects of Epidural Analgesia on Recovery After Open Colorectal Surgery

The use of epidural analgesia (EA) has been suggested as an integral part of an enhanced recovery program for colorectal surgery. However, the effects of EA on postoperative outcomes and hospital length of stay remain controversial. Data from the American College of Surgeons National Surgical Quality Improvement Program database for 2014 and 2015 were queried for adult patients who underwent elective open colorectal surgery. We included only cases with general anesthesia as the main anesthetic. Cases with other types of anesthesia were excluded. A 1:3 matched sample of EA versus non-EA cases was created based on propensity scores. The primary outcome of interest was the occurrence of major cardiopulmonary complications within 7 days of the surgery. Secondary outcome measures were hospital length of stay and 30-day mortality. A total of 24,927 patients were included in the analysis. EA was utilized in 15.02% (n = 3745). The cumulative risk over the study period for major cardiopulmonary complications was 2.52% (n = 627). There were no statistically significant differences in the rate of postoperative complications (relative risk 0.91, 95% CI 0.66–1.27, P = 0.59), length of stay (median [interquartile range], EA 6 [5–9] versus non-EA 6 [4–9] days, P = 0.36), and 30-day mortality rate (relative risk 0.71, 95% CI 0.42–1.20, P = 0.20) between the two propensity-matched cohorts. In conclusion, our study revealed that the benefits of EA in patients undergoing open colorectal surgery are limited, as it does not influence immediate postoperative cardiopulmonary complications or hospital length of stay.

BOWEL PREPERATION;

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.

Enhanced recovery after surgery care versus traditional perioperative care for elective open colorectal cancer surgery

Enhanced recovery after surgery care versus traditional perioperative care for elective open colorectal cancer surgery

Mechanical bowel preparation versus no bowel preparation in open colorectal surgery: A prospective study

Background: Colorectal surgery has always been a challenge for surgeons due to a large number of bacteria present in this area. Some of these bacteria may cause wound infection, anastomotic leak or frank sepsis. Mechanical bowel preparation (MBP) has been one of the many practices which aim to mitigate these complications. However, the use of MBP has been controversial for sometimes. We performed a prospective study to investigate the outcomes of colorectal surgery with or without MBP. Materials and Methods: This prospective study was conducted in the Department of Surgery, IGMC, Shimla from July 1, 2014 to June 30, 2015 included forty patients admitted in an emergency, or for elective open colorectal surgery. All patients who were scheduled to undergo primary resection and anastomosis of the colon and upper rectum were eligible for inclusion in the study. Results: Complications in the form of surgical site infection, wound hematoma, and enterocutaneous fistula were present in both groups. However the value of P = 0.204 in either group indicated that statistically, there was no difference between results of two groups. The average duration of stay in the no bowel preparation group was 13.42 days, and in the MBP group was 11.5 days. Conclusion: This study suggests that MBP is not necessarily essential for safe colorectal surgery.

Intra-abdominal Pressure Monitoring in Open Abdomen Management with Dynamic Abdominal Closure.

The importance of elevated intra-abdominal pressure (IAP) and abdominal compartment syndrome (ACS) have been recognized in critical care for its potential damaging effects. But, quantification of IAP values may be useful as a clinical tool for determining efficacy of coughing and straining for functional recovery of OA patients. We would like to evaluate IAP generated in an OA patient and the effect of negative pressure therapy (NPT) and dynamic abdominal closure systems (ABRA) on the IAP values at rest and during coughing and straining and compare those with IAP measurements of closed abdomen after standard open elective colorectal surgery (non-OA). Eight OA and eight non-OA patients were included in this study. OA patient with NPT and ABRA (OA + NA), OA patient without NPT and ABRA completely unbraced (OA-NA) (NA stands for NPT and ABRA), and non-OA patients underwent IAP measurements at rest, during coughing, and during straining via transurethral catheter. There was no difference in the mean of IAP measurement at rest in OA-NA (6.1mmHg), OA + NA (6.5mmHg), and non-OA (6.0mmHg) patients. During coughing, IAP of OA-NA, OA + NA, and non-OA patients were 11.5, 19.1, and 22.0mmHg and during straining, IAP of OA-NA, OA + NA, and non-OA patients were 11.5, 17.5, and 23.5mmHg, respectively. Application of NPT in conjunction with ABRA did not increase IAP at rest but provided significant IAP increase in OA + NA patients, when compared to OA-NA patients during coughing and straining. NPT in conjunction with ABRA offers the advantage of increase of IAP during coughing and straining.

Effects of Preoperative Honey Drink on Gastric Content, Perioperative Discomfort and Insulin Resistance in Patients Undergoing Open Colorectal Surgery a Randomized, Controlled Trial

Background and Aims: Preoperative fasting and surgery cause uncomfortable condition, metabolic stress and insulin resistance for the patient. A recent study in colorectal patients indicates that even small elevations of insulin resistance increase the risk of complications. Preoperative carbohydrate can reduce perioperative discomfort and insulin resistance. We investigated the effects of honey as preoperative carbohydrate-rich drink on the residual gastric contents, Original Research Article Sudiyatmo et al.; BJMMR, 14(7): 1-8, 2016; Article no.BJMMR.24374 2 perioperative discomfort, and insulin resistance. Methods: Randomized, prospective, controlled study. Thirty colorectal cancer patients who underwent elective open colorectal surgery were randomized and divided into the treatment or control group. Patients in treatment group (n = 15) received 250 ml water containing 50 ml honey on the evening and 2-3 hours preoperatively. Control patients (n = 15) underwent overnight fasting. Three different discomfort variables (thirst, hunger and tiredness), residual gastric content, plasma glucose, insulin concentrations and insulin resistance index were recorded during the perioperative period. Results: Patient and operative characteristics did not differ between groups. There was no statistical difference between the two groups with respect to gastric residue content. Subjective wellbeing was significantly better in the treatment group. Plasma glucose, serum insulin levels and insulin resistance index were found to remain significantly lower in the treatment group. Conclusion: The preoperative honey drink does not appear to alter the volume of residual gastric contents, suggesting that this is safe procedure. Preoperative honey intake is advantageous due to reducing perioperative discomfort and insulin resistance.

Factors affecting serum albumin in the perioperative period of colorectal surgery: a retrospective study.

BackgroundAlbumin is considered a negative acute-phase protein because its concentration decreases during injury and sepsis. Hypoalbuminemia is a risk factor for mortality, postoperative complications, and prolonged hospital stay. The magnitude of the systemic inflammatory response during the perioperative period, as indicated by the acute-phase proteins—C-reactive protein (CRP) in particular—, may help identify the risk of postoperative infectious complication. The correlation between serum albumin and CRP with gastrointestinal cancer has been reported. However, it is unclear whether antecedent CRP could be utilized to predict future hypoalbuminemia in the perioperative period in colorectal surgery. The primary endpoint of this study was to reveal that antecedent CRP could be utilized to predict future hypoalbuminemia in the perioperative period of colorectal surgery.MethodsThirty-seven patients who underwent elective open colorectal surgery were included in this study. Correlations between preoperative CRP and serum albumin on postoperative day (POD) 3, between preoperative CRP and serum albumin on POD 7 and between CRP on POD 3 and serum albumin on POD 7 were examined. Relationships between preoperative CRP and hypoalbuminemia on POD 3, between preoperative CRP and hypoalbuminemia on POD 7 and between CRP on POD 3 and hypoalbuminemia on POD 7 were examined by receiver operating characteristic analysis.ResultsThree-quarters of patients were older than 65 years of age. Significant correlations were observed between preoperative CRP and serum albumin on POD 3 (p = 0.023), between preoperative CRP and serum albumin on POD 7 (p = 0.023) and between CRP on POD 3 and serum albumin on POD 7 (p < 0.001). The area under the receiver operating characteristic curve of CRP on POD 3 to development of hypoalbuminemia on POD 7 was 0.833 (95 % CI 0.679–0.987) with an optimal threshold of 12.43 mg/dL, sensitivity 75 % and specificity 80 %.ConclusionsThe present study revealed that antecedent CRP was associated with future serum albumin. Additionally, CRP on POD 3 could be useful in predicting the development of hypoalbuminemia on POD 7. This result suggests that CRP on POD 3 may be a valuable indicator for early nutritional intervention.

Postoperative negative-pressure incision therapy following open colorectal surgery (Poniy): study protocol for a randomized controlled trial.

BackgroundPostoperative surgical site infections cause substantial morbidity, prolonged hospitalization, costs and even mortality, and remain one of the most frequent surgical complications. In prospective trials with adequate follow-up, more than 20 % of patients undergoing elective colorectal surgery are affected and methods to reduce surgical site infections are urgently needed. Negative-pressure incision therapy is a novel intervention that holds promise to reduce postoperative wound infection rates, but has not yet been rigorously tested in a randomized controlled trial.Methods/DesignThe aim is to investigate whether the postoperative application of a negative-pressure incision therapy device for 5–7 days reduces the rate of surgical site infections following open elective colorectal surgery by 50 %. This is a randomized, controlled, observer-blinded multicentre clinical trial with two parallel study groups. The primary outcome measure will be the rate of surgical site infections within 30 days postoperatively. Surgical site infections are defined according to criteria of the US Centers for Disease Control and Prevention. Statistical analysis of the primary endpoint measure will be based on the intention-to-treat population. The global level of significance is set at 5 % (two-sided) and the sample size (n = 170 per group) is determined to assure a power of 80 %.DiscussionThe Poniy trial will explore whether the rate of surgical site infections can be reduced by the application of a negative-pressure incision therapy device in patients undergoing open elective colorectal surgery. Its pragmatic design guarantees high external validity and clinical relevance.Trial registrationDeutsches Register Klinischer Studien DRKS00006199.

Research progression on preoperative mechanical bowel preparation for elective colorectal surgery

Preoperative mechanical bowel preparation (MBP) has been established as a standard procedure for elective colorectal surgery in most surgical centers since 1950s. However, the routine use of MBP for elective colorectal surgery is still in debate, as the researches on the evaluation of MBP have been carried out in recent 20 years. By searching and analyzing the existing evidence, we conclude that MBP should be routinely abandoned for elective open colorectal surgery, but should be routinely used for elective laparoscopic rectal surgery, and it still awaits large-scale RCTs for further evaluation of MBP for elective laparoscopic colonic surgery.

Total Occlusive Ionic Silver-Containing Dressing vs Mupirocin Ointment Application vs Conventional Dressing in Elective Colorectal Surgery: Effect on Incisional Surgical Site Infection

Several pre- and intraoperative factors have been associated with incisional surgical site infection (SSI), but little is known about the influence of postoperative wound care and especially, the use of different dressings on incisional SSI. The aim of this study was to compare 3 methods of wound dressings (conventional dressing, silver-containing dressing, and mupirocin ointment dressing) for their ability to prevent SSI, as measured by SSI rates, in patients with colorectal cancer undergoing elective open surgery. A prospective, randomized study was performed. Inclusion criteria were diagnosis of colorectal neoplasms and plans to undergo elective surgery with curative aims. Patients were randomized using a 1:1:1 allocation into 3 groups: patients receiving an ionic silver-containing dressing (ISD) (group 1), a mupirocin ointment application (MOA) (group 2), and a conventional dressing (group 3 or standard dressing). The primary outcomes variable was occurrence of incisional SSI. Follow-up was 30 days postoperatively. A total of 147 patients were included, 49 in each group. Incisional SSI occurred in 9 patients (18.4%) in the ISD group, 2 (4.1%) in the MOA group, and 10 (20.4%) in the standard dressing group (p = 0.028). Adjusting for multiple comparisons, there were no significant differences between ISD and standard dressing groups; a significant difference was observed between ISD and MOA (relative risk [RR] 4.5; 95% CI (1.1 to 19.8); p = 0.046) and between the standard group and the MOA group (RR 5; 95% CI (1.2 to 21.7); p = 0.031). Topical application of mupirocin ointment achieves better results for the prevention of SSI than ionic silver-containing dressing or standard dressing in patients undergoing elective open colorectal surgery.

Risk Factors for Abdominal Incision Infection after Colorectal Surgery in a Saudi Arabian Population: The Method of Surveillance Matters.

Reported surgical site infection rates range from 2.1% to 40% after colorectal surgery and are believed to be underestimated depending on the method of surveillance. The study aims were to identify an accurate incidence and associated risk factors for abdominal incision surgical site infection after elective open colorectal surgery in a Saudi population. This was a prospective observational longitudinal study of 300 consecutive adult patients, recruited upon admission to an 800-bed tertiary referral center. All consenting adults admitted for elective open colorectal surgery were included. Patients were followed for 36 d post-surgery by two certified and experienced wound care experts who diagnosed abdominal incision surgical site infections. The definition provided by the U.S. Centers for Disease Control and Prevention was used. Statistical analysis was performed using both univariate and multivariable logistic regression. Data were analyzed for 296 patients; the incidence of abdominal surgical site infection was 30%. Factors associated with surgical site infection by univariate analysis were pre-operative pre-albumin (p=0.04, odds ratio [OR] 0.81, 95% confidence interval [CI] 0.66-0.99); operative difficulty because of truncal obesity (p=0.006, OR 2.19, 95% CI 1.25-3.84) and obesity measured by body mass index (p=0.002, OR 4.00, 95% CI 1.95-8.20). Multivariable analysis identified only two significant risk factors: Pre-operative pre-albumin (p=0.02, OR 0.76, 95% CI 0.60-0.96), and obesity measured by body mass index (BMI; p=0.001, OR 4.71, 95% CI 2.20-10.10). Obesity and nutritional status correlated with post-operative abdominal surgical site infection. The method of surveillance and length of follow-up impact the rate reported.

Short-term results of quality of life for curatively treated colorectal cancer patients in Lithuania

Background and objectiveTreatment options for colorectal cancer patients create the need to assess the quality of life (QoL) of colorectal cancer patients in the early postoperative period when changes are potentially greatest. The aim of the current study was to assess the QoL of colorectal cancer patients following open and laparoscopic colorectal surgery. Materials and methodsA total of 82 consecutive patients requiring elective open or laparoscopic colorectal surgery were recruited to the study for 3 months in the three colorectal surgery centers of Lithuania. Patients completed the EORTC QLQ-C30 (version 3.0) questionnaire before surgery, 2 and 5 days, 1 and 3 months after operation. The EORTC QLQ-CR29 questionnaire was completed before surgery and at 1 and 3 months after operation. Analysis was done according to the manual for each instrument. ResultsEORTC QLQ-C30 reflected the postoperative recovery of QoL. The global health status, cognitive and emotional functioning came back to the preoperative level in one month after operation. Physical and role functioning for laparoscopic group was significantly improved in 1 month after operation and in 3 months for open surgery group respectively. Colorectal module EORTC-QLQ-CR29 found that future perspective increased significantly in laparoscopic group 1 month after operation. ConclusionsThe present study showed that majority of functional scale scores came back to the preoperative level during the first 3 months after colorectal cancer surgery. Differences in QoL according to surgical approach are mostly expressed on this period.

In Reply

We thank Dr. Harper for his comments and interest on our recent study published in Anesthesiology.1We fully agree with the author that complete compliance with the enhanced recovery after surgery recommendations would have involved absence of mechanical bowel preparation (MBP) in left-sided colonic surgery. Nevertheless, the largest systematic review on the role of MBP in colonic surgery (including approximately 5,000 patients) failed to demonstrate harmful effects of MBP in terms of anastomotic leakage.2 In addition, two large-scale randomized controlled trials3,4 suggested more deep intraabdominal abscesses in the absence of MBP and a significant benefit in patients who had MBP. It has also been shown that preoperative MBP is useful when intraoperative colonoscopy is required to precisely locate small tumors. Finally, although MBP has adverse physiologic effects attributed to dehydration, omission of preoperative fasting and use of individualized goal-directed fluid administration may easily and effectively compensate for this.We respectfully disagree with the author when stated that midline incision may not represent current daily for colorectal surgery. To the best of knowledge, current recommendations do not advocate use of transverse or oblique incisions for open colorectal surgery. Since the publication of the Cochrane review, the Postsurgical Pain Outcome of Vertical and Transverse Abdominal Incision randomized controlled trial5 has shown no relevant difference in pain scores and postoperative morbidity between incision types after major abdominal procedures, whereas more wound infections were seen after transverse incisions. Although problematic, these concerns are not the most important ones. Indeed, as a possible clinical benefit of wound catheters placement in oblique and/or transverse incisions has never been explored during colorectal surgery, any comparison between continuous wound analgesia, as an interventional treatment group in this setting, and epidural analgesia would have been only speculative.Until more thorough studies addressing the question have been carried out, our opinion is that there is no sufficient evidence to shift from epidural analgesia to continuous wound infiltration of local anesthetics in elective open colorectal surgery. We are convinced that the soon-to-be-published Dr. Harper’s study will help provide answers to the many remaining questions regarding the optimal analgesic regimen in open colorectal surgery.

Influence of enhanced recovery after surgery pathways and laparoscopic surgery on health‐related quality of life

This study set out to compare the postoperative health related quality of life (HQoL) of patients undergoing elective open colorectal surgery using a well-established enhanced recovery after surgery (ERAS) pathway with those undergoing laparoscopic surgery without an established an ERAS pathway. Using a power calculation, it was estimated that 40 patients would be required in each group. HQoL of the two groups was prospectively assessed using SF-12 (Short Form 12) and EORTC QLQ 30 (European Organisation of Research and Treatment of Cancer, Quality of Life Questionnaire) preoperatively, and at 2 and 6weeks after discharge. Data were collected from 83 patients, 41 in the laparoscopic group and 42 in the open-ERAS group. There was a significant difference between the median length of stay of the open-ERAS (5days) and laparoscopic (7days, P=0.028) groups. There were no significant differences between the HQoL score of the two groups at any stage. In both groups, the majority of HQoL scores had improved considerably by 6weeks. Laparoscopic and open-ERAS surgery have a similar impact on postoperative HQoL. HQoL tends to improve by the 6-week stage.