Intrathecal analgesia and restrictive perioperative fluid management within enhanced recovery pathway: hemodynamic implications.

BACKGROUND: Intrathecal analgesia and avoidance of perioperative fluid overload are key items within enhanced recovery pathways. Potential side effects include hypotension and renal dysfunction. STUDY DESIGN: From January 2010 until May 2010, all patients undergoing colorectal surgery within enhanced recovery pathways were included in this retrospective cohort study and were analyzed by intrathecal analgesia (IT) vs none (noIT). Primary outcomes measures were systolic and diastolic blood pressure, mean arterial pressure, and heart rate for 48 hours after surgery. Renal function was assessed by urine output and creatinine values. RESULTS: One hundred and sixty-three consecutive colorectal patients (127 IT and 36 noIT) were included in the analysis. Both patient groups showed low blood pressure values within the first 4 to 12 hours and a steady increase thereafter before return to baseline values after about 24 hours. Systolic and diastolic blood pressure and mean arterial pressure were significantly lower until 16 hours after surgery in patients having IT compared with the noIT group. Low urine output (<0.5 mL/kg/h) was reported in 11% vs 29% (IT vs noIT; p = 0.010) intraoperatively, 20% vs 11% (p = 0.387), 33% vs 22% (p = 0.304), and 31% vs 21% (p = 0.478) for postanesthesia care unit and postoperative days 1 and 2, respectively. Only 3 of 127 (2.4%) IT and 1 of 36 (2.8%) noIT patients had a transitory creatinine increase >50%; no patients required dialysis. CONCLUSIONS: Postoperative hypotension affects approximately 10% of patients within an enhanced recovery pathway and is slightly more pronounced in patients with IT. Hemodynamic depression persists for <20 hours after surgery; it has no measurable negative impact and therefore cannot justify detrimental postoperative fluid overload

Simple Clinical Screening Underestimates Malnutrition in Surgical Patients with Inflammatory Bowel Disease-An ACS NSQIP Analysis.

The present large scale study aimed to assess the prevalence and consequences of malnutrition, based on clinical assessment (body mass index and preoperative weight loss) and severe hypoalbuminemia (<3.1 g/L), in a representative US cohort undergoing IBD surgery. The American College of Surgeons National Quality improvement program (ACS-NSQIP) Public User Files (PUF) between 2005 and 2018 were assessed. A total of 25,431 patients were identified. Of those, 6560 (25.8%) patients had severe hypoalbuminemia, 380 (1.5%) patients met ESPEN 2 criteria (≥10% weight loss over 6 months PLUS BMI < 20 kg/m <sup>2</sup> in patients <70 years OR BMI < 22 kg/m <sup>2</sup> in patients ≥70 years), and 671 (2.6%) patients met both criteria (severe hypoalbuminemia and ESPEN 2). Patients who presented with malnutrition according to any of the three definitions had higher rates of overall, minor, major, surgical, and medical complications, longer LOS, higher mortality and higher rates of readmission and reoperation. The simple clinical assessment of malnutrition based on BMI and weight loss only, considerably underestimates its true prevalence of up to 50% in surgical IBD patients and calls for dedicated nutritional assessment

Cost drivers of locally advanced rectal cancer treatment-An analysis of a leading healthcare insurer.

To evaluate the economic burden of locally advanced rectal cancer (LARC) treatment from a society perspective through analysis of health insurance-derived data of commercially insured and Medicare Advantage (MA) patients. Retrospective cost analysis of patients undergoing rectal resection within a multimodal (neoadjuvant chemoradiation + adjuvant chemotherapy) treatment strategy between January 1, 2010 and October 31, 2018, using the claims OptumLabs Data Warehouse database. In total, 1738 (935 commercial and 803 MA) patients were included. Overall treatment costs totaled $230,881,746 (on average$183 653 ± 82 384 per commercially insured and $73 681 ± 32 917 per MA patient). Cost distribution according to category (commercially insured patients) was: 29.92% related to outpatient care (follow-up visits/diagnostics), radiotherapy: 21.83%, index resection: 20.62%, chemotherapy: 17.44%, surgical inpatient: 6.32%, medical inpatient: 3.28%, emergency room: 0.58%. Relative cost distribution of the index resection itself differed marginally between the three approaches and was 21.49% for open, 19.30% for laparoscopic, and 20.93% for robotic surgery. Relative cost distributions of neoadjuvant, adjuvant, and outpatient treatments remained unchanged, independently of the surgical approach. This representation was similar in MA patients. Index-surgery related costs were outweighed by costs related to oncological and outpatient workup/follow-up treatments independently of both surgical approach and insurance type

Trends of complications and innovative techniques' utilization for colectomies in the United States.

Despite an increasing trend towards utilization of minimally invasive approaches (MIS), results regarding their safety profile are contradictory. All patients who underwent elective colectomy for any underlying disease with an identifiable operative approach available from the targeted colectomy files of the ACS-NSQIP PUFs 2013 to 2018 were included. The trend of utilization and complication rates of the different operative approaches (open, laparoscopic, robotic) were assessed during the inclusion period. Furthermore, overall, surgical, and medical complications were compared between the three approaches. The study cohort included 78,987 patients. Of them, 12,335 (15.6%) patients underwent open, 57,874 (73.3%) laparoscopic, and 8,778 (11.1%) robotic surgery. There was an increasing trend towards the utilization of robotic surgery (2.5% increase per year) at the expense of the other approaches. With the increasing trend toward the utilization of the robotic approach, a decreasing trend in overall and surgical complications and length of stay was observed. After adjusting for the baseline confounders, robotic surgery was associated with shorter length of stay, lower rate of overall (OR 0.397; p < 0.05 compared to open and OR: 0.763; p < 0.05 compared to laparoscopy) and surgical complications (OR: 0.464; p < 0.05 compared to open and OR: 0.734; p < 0.05 compared to laparoscopy). This study revealed an increasing trend toward the utilization of MIS for elective colectomy in the US. Robotic surgery was associated with a decreasing trend in overall and surgical morbidity and length of stay

Survival impact of adjuvant chemotherapy in patients with stage IIA colon cancer: Analysis of the National Cancer Database.

Utility of adjuvant chemotherapy for stage II cancer remains a matter of debate. Clinical guidelines suggest adjuvant chemotherapy for stage II tumors with high-risk features, in particular T4 tumors. However, limited consensus exists regarding the importance of other high-risk features (lymphovascular or perineural invasion, microsatellite instability). Our study aimed to investigate the impact of adjuvant chemotherapy for stage IIA (T3N0) colon cancer patients. Patients who underwent colectomy for stage IIA colon adenocarcinoma (2010-2015) were identified in the National Cancer Database (NCDB) and divided in two groups based on receipt of adjuvant chemotherapy vs observation. Inverse probability of treatment weighting (IPTW)-adjusted Kaplan-Meier and Cox proportional hazards regression analyses were performed to compare overall survival between the two groups. Subgroup analysis of patients with specific high-risk features LVI, PNI and MSI was performed. Among 46 688 surgical patients with stage IIA colon adenocarcinoma 5937 (12.7%) received adjuvant chemotherapy, while 40 751 (87.3%) were observed. Five-year IPTW-adjusted survival was higher in the adjuvant chemotherapy group (79.7% [95% CI 79.1, 80.2]) compared to the observation group (70.3% [95% CI 69.7, 70.9]). Patients with high-risk pathological features showed an estimated 5-year survival benefit of 11.3% (78.2% [95% CI 77.4, 79.1] vs 66.9% [95% CI 65.9, 67.8]) when treated with adjuvant chemotherapy. This NCDB analysis revealed a survival benefit for patients with stage IIA colon adenocarcinoma and high-risk features that were treated with adjuvant chemotherapy

Readmissions Within 48 Hours of Discharge: Reasons, Risk Factors, and Potential Improvements.

Hospital readmission rate is an important quality metric and has been recognized as a key measure of hospital value-based purchasing programs. This study aimed to assess the risk factors for hospital readmission with a focus on potentially preventable early readmissions within 48 hours of discharge. This is a retrospective cohort study. This study was conducted at a tertiary academic facility with a standardized enhanced recovery pathway. Consecutive patients undergoing elective major colorectal resections between 2011 and 2016 were included. Univariable and multivariable risk factors for overall and early (<48 hours) readmissions were identified. Specific surgical and medical reasons for readmission were compared between early and late readmissions. In total, 526 of 4204 patients (12.5%) were readmitted within 30 days of discharge. Independent risk factors were ASA score (≥3; OR, 1.5; 95% CI, 1.1-2), excess perioperative weight gain (OR, 1.7; 95% CI, 1.3-2.3), ileostomy (OR, 1.4; 95% CI, 1-2), and transfusion (OR, 2; 95% CI, 1.4-3), or reoperation (OR, 11.4; 95% CI, 7.4-17.5) during the index stay. No potentially preventable risk factor for early readmission (128 patients, 24.3% of all readmissions, 3% of total cohort) was identified, and index hospital stay of ≤3 days was not associated with increased readmission (OR, 0.9; 95% CI, 0.7-1.2). Although ileus and small-bowel obstruction (early: 43.8% vs late: 15.5%, p < 0.001) were leading causes for early readmissions, deep infections (3.9% vs 16.3%, p < 0.001) and acute kidney injury (0% vs 5%, p = 0.006) were mainly observed during readmissions after 48 hours. Risk of underreporting due to loss of follow-up and the potential co-occurrence of complications were limitations of this study. Early hospital readmission was mainly due to ileus or bowel obstruction, whereas late readmissions were related to deep infections and acute kidney injury. A suspicious attitude toward potential ileus-related symptoms before discharge and dedicated education for ostomy patients are important. A short index hospital stay was not associated with increased readmission rates. See Video Abstract at http://links.lww.com/DCR/B237. REINGRESOS DENTRO DE LAS 48 HORAS POSTERIORES AL ALTA: RAZONES, FACTORES DE RIESGO Y POSIBLES MEJORAS: La tasa de reingreso hospitalario es una métrica de calidad importante y ha sido reconocida como una medida clave de los programas hospitalarios de compras basadas en el valor.Evaluar los factores de riesgo para el reingreso hospitalario con énfasis en reingresos tempranos potencialmente prevenibles dentro de las 48 horas posteriores al alta.Estudio de cohorte retrospectivo.Institución académica terciaria con programa de recuperación mejorada estandarizado.Pacientes consecutivos sometidos a resecciones colorrectales mayores electivas entre 2011 y 2016.Se identificaron factores de riesgo uni y multivariables para reingresos totales y tempranos (<48 horas). Se compararon razones médicas y quirúrgicas específicas para el reingreso entre reingresos tempranos y tardíos.En total, 526/4204 pacientes (12,5%) fueron readmitidos dentro de los 30 días posteriores al alta. Los factores de riesgo independientes fueron puntuación ASA (≥3, OR 1.5; IC 95% 1.1-2), aumento de peso perioperatorio excesivo (OR 1.7; IC 95% 1.3-2.3), ileostomía (OR 1.4, IC 95%: 1-2) y transfusión (OR 2, IC 95% 1.4-3) o reoperación (OR 11.4; IC 95% 7.4-17.5) durante la estadía índice. No se identificó ningún factor de riesgo potencialmente prevenible para el reingreso temprano (128 pacientes, 24.3% de todos los reingresos, 3% de la cohorte total), y la estadía hospitalaria índice de ≤ 3 días no se asoció con un aumento en el reingreso (OR 0.9; IC 95% 0.7-1.2) Mientras que el íleo / obstrucción del intestino delgado (temprano: 43.8% vs. tardío: 15.5%, p < 0.001) fueron las principales causas de reingresos tempranos, infecciones profundas (3.9% vs 16.3%, p < 0.001) y lesión renal aguda (0 vs 5%, p = 0.006) se observaron principalmente durante los reingresos después de 48 horas.Riesgo de subregistro debido a la pérdida en el seguimiento, posible co-ocurrencia de complicaciones.El reingreso hospitalario temprano se debió principalmente a íleo u obstrucción intestinal, mientras que los reingresos tardíos se relacionaron con infecciones profundas y lesión renal aguda. Es importante tener una actitud suspicaz hacia los posibles síntomas relacionados con el íleo antes del alta y una educación específica para los pacientes con ostomía. La estadía hospitalaria índice corta no se asoció con mayores tasas de reingreso. Consulte Video Resumen en http://links.lww.com/DCR/B237

Ordering a Normal Diet at the End of Surgery-Justified or Overhasty?

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

Renal pericytes: regulators of medullary blood flow

Regulation of medullary blood flow (MBF) is essential in maintaining normal kidney function. Blood flow to the medulla is supplied by the descending vasa recta (DVR), which arise from the efferent arterioles of juxtamedullary glomeruli. DVR are composed of a continuous endothelium, intercalated with smooth muscle-like cells called pericytes. Pericytes have been shown to alter the diameter of isolated and in situ DVR in response to vasoactive stimuli that are transmitted via a network of autocrine and paracrine signalling pathways. Vasoactive stimuli can be released by neighbouring tubular epithelial, endothelial, red blood cells and neuronal cells in response to changes in NaCl transport and oxygen tension. The experimentally described sensitivity of pericytes to these stimuli strongly suggests their leading role in the phenomenon of MBF autoregulation. Because the debate on autoregulation of MBF fervently continues, we discuss the evidence favouring a physiological role for pericytes in the regulation of MBF and describe their potential role in tubulo-vascular cross-talk in this region of the kidney. Our review also considers current methods used to explore pericyte activity and function in the renal medulla