Aim: Postoperative ileus is an important factor of complications following gastrointestinal procedures. Its pathophysiology and the parameters, which may impact on its duration, remain unclear. The aim of this study was to measure the role of various clinical determinants on restoration of intestinal function after elective colorectal surgery. Methods: From July 2002 to September 2003, all patients who underwent laparotomy for colectomy (laparoscopic resections excluded) with either an ileotransverse, colocolic, or high colorectal anastomosis were entered in this prospective study. The intervals in hours between the end of the surgical procedure and passing of flatus (PG) and passing of stool (PS) were recorded by an independent investigator. PG and PS were eventually correlated with the following parameters: type of colectomy, early removal of nasogastric tube (NGT), mechanical bowel preparation (MBP), type of underlying disease, systemic administration of opiates, and surgical training (colorectal fellowship or other). Results: One hundred twenty-four patients were entered in this study. Four patients (3.2%) developed septic complications (3 anastomotic leaks and 1 intraabdominal abscess) and were excluded from the analysis. Median age in this population was 68 (range 30-95) years. Mean duration of postoperative ileus was 70±28h (PG) and 99±34h (PS). The type of colectomy, underlying disease, MBP, and early NGT removal failed, in univariate analysis, to correlate with the duration of postoperative ileus. By contrast, time intervals PG and PS were statistically shorter in the group of patients treated by a colorectal surgeon [56±23 vs 74±28h (PG); 82±26 vs 103±35h (PS), p=0.004], as well as in patients who received systemic opiates for less than 2days [64±27 vs 75±28h (PG), p=0.04; 88±32 vs 108±33h (PS), p=001]. Conclusion: Restoration of normal intestinal function after elective open colectomy takes 3 (PG) to 4 (PS) days. In our series, specialized training in colorectal surgery has a positive impact on the duration of postoperative ileus. Surgical specialization should be considered an important parameter in future clinical trials aiming to minimize postoperative ileu

Bucher, Pascal

Gervaz, Pascal

Morel, Philippe

Mugnier-Konrad, Béatrice

Scheiwiller, Andreas

RERO DOC Digital Library

Int J Colorectal Dis (2006) 21: 542–546DOI 10.1007/s00384-005-0050-0 ORIGINAL ARTICLEPascal GervazPascal BucherAndreas ScheiwillerBéatrice Mugnier-KonradPhilippe MorelAccepted: 28 September 2005Published online: 3 November 2005# Springer-Verlag 2005The duration of postoperative ileusafter elective colectomy is correlatedto surgical specializationAbstract Aim: Postoperative ileus isan important factor of complicationsfollowing gastrointestinal procedures.Its pathophysiology and the param-eters, which may impact on itsduration, remain unclear. The aim ofthis study was to measure the role ofvarious clinical determinants on res-toration of intestinal function afterelective colorectal surgery. Methods:From July 2002 to September 2003,all patients who underwent laparoto-my for colectomy (laparoscopic re-sections excluded) with either anileotransverse, colocolic, or high co-lorectal anastomosis were entered inthis prospective study. The intervals inhours between the end of the surgicalprocedure and passing of flatus (PG)and passing of stool (PS) were re-corded by an independent investigator.PG and PS were eventually correlatedwith the following parameters: type ofcolectomy, early removal of nasogas-tric tube (NGT), mechanical bowelpreparation (MBP), type of underlyingdisease, systemic administration ofopiates, and surgical training (colo-rectal fellowship or other). Results:One hundred twenty-four patientswere entered in this study. Fourpatients (3.2%) developed septiccomplications (3 anastomotic leaksand 1 intraabdominal abscess) andwere excluded from the analysis.Median age in this population was68 (range 30–95) years. Mean dura-tion of postoperative ileus was 70±28 h (PG) and 99±34 h (PS). Thetype of colectomy, underlying disease,MBP, and early NGT removal failed,in univariate analysis, to correlatewith the duration of postoperativeileus. By contrast, time intervals PGand PS were statistically shorter in thegroup of patients treated by a colo-rectal surgeon [56±23 vs 74±28 h(PG); 82±26 vs 103±35 h (PS),p=0.004], as well as in patients whoreceived systemic opiates for less than2 days [64±27 vs 75±28 h (PG),p=0.04; 88±32 vs 108±33 h (PS),p=001]. Conclusion: Restoration ofnormal intestinal function after elec-tive open colectomy takes 3 (PG) to 4(PS) days. In our series, specializedtraining in colorectal surgery has apositive impact on the duration ofpostoperative ileus. Surgical special-ization should be considered an im-portant parameter in future clinicaltrials aiming to minimize postopera-tive ileus.Keywords Colectomy . Surgery .Ileus . Specialization . OutcomeIntroductionPostoperative ileus is an inevitable response to peritonealirritation and is best defined as the uncomplicated ileusoccurring following surgery, which usually resolvesspontaneously within 2 to 3 days [1]. Although its duration,due to the lack of objective endpoint, is somewhat difficultto determine, there is evidence that postoperative ileusP. Gervaz . P. Bucher . A. Scheiwiller .B. Mugnier-Konrad . P. MorelDepartment of Surgery,University Hospital of Geneva,Geneva, SwitzerlandP. Gervaz (*)Service de Chirurgie Viscérale, HôpitalUniversitaire de Genève,24 rue Micheli-du-Crest,1211 Geneva, Switzerlande-mail: pascal.gervaz@hcuge.chTel.: +41-22-3727703Fax: +41-22-3727707correlates with surgical trauma, and that it is most extensiveafter colonic surgery [2]. As a result, postoperative ileus isa significant medical problem after colorectal procedures,being simultaneously a factor of discomfort for the patientand of prolonged hospital stay [3].After abdominal surgery, inhibition of small bowelmotility is transient, and the stomach recovers within 24 to48 h, whereas colonic function takes 2 to 3 days to return.Pathogenesis of postoperative ileus remains to date elusiveand is probably multifactorial: Sympathetic spinal reflexes[4], inflammatory mediators released as part of stress re-sponse [5], and systemic opiates [6], all have an inhibitoryeffect on gastrointestinal motility and contribute to postop-erative ileus.Methods for preventing or for reducing the durationof postoperative ileus have recently attracted increasedscrutiny [7]: Continuous thoracic epidural analgesia [8],early mobilization, and enteric nutrition [9], as well as areduction in doses of systemic opiates [10] may all have apositive impact on recovery of bowel function after majorabdominal surgery. By comparison, methods aiming forreducing surgical trauma have so far focused more on therole of the surgical approach (laparoscopic vs open) ratherthan on the role of the surgeon himself [11, 12].We hypothesized that surgical specialization may havea significant impact on postoperative ileus in patientsscheduled to undergo abdominal procedures. The aim ofthe study was therefore to prospectively correlate colorectalsurgical training, as well as other clinical parameters, withthe time to restoration of normal bowel function afterelective, standardized colectomy.MethodsFrom July 2002 to September 2003, all patients whounderwent laparotomy for colectomy in the Department ofSurgery at University Hospital Geneva were entered in thisprospective study. This institution is a teaching center, withmore than 400 colorectal procedures performed annually, arelatively high percentage of them (30%) on an emergentbasis. Three senior consultants and 12 junior staff membersroutinely perform colorectal surgery with a general surgerybackground (10 years of experience at least). All of themhave developed, during their training, a special interest for aspecific area of digestive surgery (liver surgery, transplant,minimally invasive). However, one surgeon has receivedsubspecialty training in a nationally approved colorectalsurgery program overseas.The exclusion criteria were as follows: nonelectiveprocedures, laparoscopic or laparoscopically assisted opera-tions, operations with associated resection of other intraab-dominal organs, extended colectomies or atypical resections,low anterior resections and proctectomies, and the necessityto create a stoma either terminal or defunctioning. Basicallythe patients who were deemed eligible underwent electivelyeither a right or a left colectomy with an ileotransverse or acolocolic or high colorectal anastomosis, respectively. In ourinstitution, bowel preparation is not used before rightcolectomies, and some of the patients in the present studywere simultaneously enrolled in a prospective, randomizedstudy on the role of bowel preparation before left-sidedcolorectal surgery.The intervals in hours between the end of the surgicalprocedure and passing of flatus (PG) and passing of stool(PS) were recorded by a clinical research nurse who wasblinded to of the tested clinical parameters and who visitedthe patients on a daily basis.PG and PS were eventually correlated with the followingparameters, which were considered potential importantparameters affecting bowel function following colectomy:patients’ demographics, type of colectomy (right or left),early removal of nasogastric tube (NGT) (less than or morethan 24 h postoperatively), mechanical bowel preparation(MBP) prior to surgery (left colectomies only), type ofunderlying disease (cancer or other), systemic administra-tion of opiates (less than or more than 48 h), and surgicaltraining (colorectal fellowship or general surgery training).Statistical analysisStatistical analyses were undertaken by means of thesoftware package STATGRAPH 3.0 software for Windows(Statgraph Software Inc., San Diego, CA). Quantitative datawere expressed asmean±SD.Group comparisons weremadeusing two-sided Fisher’s exact test for categorical variablesand two-sided Student’s t test for continuous variables. Thena multivariate analysis was undertaken using the softwareGB-STAT (Dynamic Microsystems Inc., Silver Spring, MD,USA). Multiple strait regression models were used to test therelation of the identified independent factors to the dependantvariable PG or PS with cutoff values of less than or at least48 h. P values less than or equal to 0.05 were consideredstatistically significant.ResultsFrom July 2002 to September 2003, 124 patients whounderwent laparotomy for an elective right or left colectomywith either an ileotransverse, colocolic, or high colorectalanastomosis were entered in this prospective study. Fourpatients (3.2%) developed septic complications (3 anasto-motic leaks and 1 intraabdominal abscess) and were ex-cluded from the analysis, leaving 120 patients who constitutethe population studied herein. Median age in this group was68 (range 30–95) years. There were 64 men and 56 women.The main indication for surgery was cancer (97 cases),diverticulosis, endometriosis, and Crohn’s disease. Proce-dures performed included 50 right and 70 left colectomies;NGTwas removed less than 24 h after surgery in 45 (37.5%)543cases. Seventy patients (58%) did not receive any bowelpreparation.A single colorectal surgeon performed 27 colectomies(22.5%). The comparison of patients operated by special-ized vs general surgeons is summarized in Table 1. Pa-tients operated by a colorectal surgeon were more likely tobe operated on for conditions other than cancer, such asCrohn’s disease and endometriosis, and showed a trendtowards a higher proportion of left colectomies. The otherdemographics and surgical parameters were not signifi-cantly different between groups.For the whole group, mean±SD duration of postopera-tive ileus was 70±28 h (PG) and 99±34 h (PS). The type ofcolectomy (p=0.78), underlying disease (p=0.73), MBP(p=0.15), and early NGT removal (p=0.22) were allparameters which failed, in univariate analysis, to correlatewith the duration of postoperative ileus. By contrast, timeintervals PG and PS were statistically shorter in the groupof patients treated by a colorectal surgeon [56±23 vs 74±28 h (PG); 82±26 vs 103±35 h (PS), p=0.004]. Similarly,patients who received systemic opiates for less than 48 hhad a shorter duration of ileus [64±27 vs 75±28 h (PG),p=0.04; 88±32 vs 108±33 h (PS), p=001]. The impact ofvarious clinical parameters on the duration of postoperativeileus is summarized in Tables 2 and 3.In multivariate analysis, the two factors (surgical special-ization and systemic opiates for less than 48 h), previouslyidentified, emerged again as significant predictors of short-ened postoperative ileus. The results of the multivariateanalysis are summarized in Tables 4 and 5. Surgical spe-cialization was the only parameter which was consistentlyassociated with a shortened postoperative ileus, whether itwas measured by the time to PG or the time to PS.Table 2 Impact of variables on postoperative passing of stoolsVariable Ileus (h) p valueType of procedure 0.78Right colectomy 98±35Left colectomy 99±33Indication for surgery 0.73Cancer 101±43Other 98±32Bowel preparation 0.15No 93±34Yes 102±34Early removal NGT 0.22No 102±35Yes 94±32Surgical specialization 0.004No 103±35Yes 82±26Systemic opioids 0.001<48 h 88±32>48 h 108±33Table 3 Impact of variables on postoperative passing of gasVariable Ileus (h) p valueType of procedure 0.63Right colectomy 68±27Left colectomy 71±29Indication for surgery 0.66Cancer 69±26Other 72±37Bowel preparation 0.78No 70±29Yes 69±27Early removal NGT 0.12No 73±27Yes 65±29Surgical specialization 0.004No 74±28Yes 56±23Systemic opioids 0.04<48 h 64±27>48 h 75±28Table 1 Comparison of clinical parameters according tosurgeonsVariable General surgeon,N=93Colorectal surgeon,N=27pvalueaAge (median,range)71 (31–95) 69 (30–84) 0.30Gender 0.38Male 52 12Female 41 15Underlyingdisease0.01Cancer 80 17Other 13 10Type ofprocedure0.07Right colectomy 43 7Left colectomy 50 20Bowelpreparation0.50Yes 37 13No 56 14Systemic opioids 0.66<48 h 42 14>48 h 51 13Early removalNGT0.65<24 h 36 9>24 h 57 18NGT nasogastric tubeaUnpaired t test or Fisher’s exact test when appropriate544DiscussionRestoration of normal intestinal function after electiveopen colectomy takes 3 (PG) to 4 (PS) days. The resultspresented here indicate that specialized training in colo-rectal surgery has a positive impact on the duration ofpostoperative ileus after elective colectomy; the otherclinical parameter having a similar impact is the reductionin systemic administration of opiates. The other variablestested, such as the type of colectomy, the early removal ofNGT, as well as the indication for surgery did not influencethe duration of postoperative ileus.Assessing postoperative ileus has proven difficult due tothe lack of good objective endpoint, and bowel movementsare certainly not a reliable indicator of the exact time ofresolution of ileus; nevertheless, most clinicians would agreethat it is probably the most objective measure and that, incombination with the passage of flatus [also known by theacronymof flatus and return of transit (FART); ReadTE], canbe considered a good estimate of the return of bowelfunction. In our series, postoperative ileus lasted 3–4 days,and colonic transit occurred 24 h after flatus, which is inaccordance with most previously published series [13–15].Surgeon-dependent differences in outcome are now welldocumented in patients with rectal [16–18] and breast [19]cancer; importantly, these differences seem to reflect thedegree of specialization rather than case volume [20]. Thecolorectal surgeon working in our institution is mostlyinvolved in pelvic surgery for rectal cancer or ulcerativecolitis and did not perform more colectomies than otherstaff surgeons. However, the duration of postoperative ileuswas strongly correlated with subspecialty training, witha reduction by nearly 24 h of postoperative ileus in com-parison with patients operated on by general surgeons. Thisdifference in magnitude is clinically relevant and is quan-titatively similar to the impact of a reduced administrationof systemic opiates.An important limitation of our study is that the colorectalsurgeon group is comprised of surgeries performed by onlyone surgeon, and that, accordingly, the effect of subspecialtytraining is confounded with the skills and experience of thissurgeon. There is also a potential for patient selection bias,but very unlikely to favor the colorectal surgeon group,which included cases considered more difficult. Of note,there was a preponderance of cancers, and a trend towardright colectomies in the group operated by general surgeons;this also may have influenced our results. By contrast, pre-and postoperative management appeared relatively consis-tent between groups, with similar approaches regarding useof NGT and bowel preparation, as well as administration ofopiates. Similarly, anesthetic techniques were distributedrandomly between groups. Thus, most of the differencesobserved are likely to be related to the procedure itself.In summary, the differences observed seem to be related, atleast in part, to a reduction in surgical trauma by minimizinghandling of the small bowel, shortening operating time, aswell as conducting dissection in anatomical planes, withsubsequent reduction in bleeding and need for postoperativetransfusions. Unfortunately, in this study, these differenceswere not correlated with the duration of hospital stay, due tosome specificities in the Swiss Health Insurance system,which make this parameter irrelevant for analysis. Our datademonstrate that specialized training in colorectal surgeryhas a positive impact on the duration of postoperative ileusafter elective colectomy. Subspecialty training should beconsidered an important parameter in future clinical trialsaiming to minimize postoperative ileus [14], [17].Table 4 Multivariate analysis of factors for passing of stoolsVariable t value p valueSurgical specialization 3.13 0.002NGT removal 0.57 0.57Systemic opiates 2.62 0.01Type of colectomy 1.31 0.19Indication for surgery 1.93 0.055Table 5 Multivariate analysis of factors for passing of gasVariable Ileus (h) p valueSurgical specialization 3.32 0.001NGT removal 0.34 0.73Systemic opiates 1.02 0.31Type of colectomy 0.68 0.49Indication for surgery 1.4 0.16References1. Livingston EH, Passaro EP (1990)Postoperative ileus. Dig Dis Sci35:121–1322. Huge A, Kreis ME, Jehle EC, EhrleinHJ, Starlinger M et al (1998) A modelto investigate postoperative ileus withstrain gauge transducers in awake rats.J Surg Res 74:112–1183. Luckey A, Livingston E, Taché Y(2003) Mechanisms and treatment ofpostoperative ileus. Arch Surg138:206–2145454. de Jonge WJ, van den Wijngaard RM,The FO, ter Beek ML, et al (2003)Postoperative ileus is maintained byintestinal immune infiltrates that acti-vate inhibitory neural pathways inmice. Gastroenterology 125:1137–11475. Kalff JC, Wolfgang HS, Simmons RL,Bauer AJ (1998) Surgical manipulationof the gut elicits an intestinal inflam-matory response resulting in post-sur-gical ileus. Ann Surg 228:652–6636. Cali RL, Meade PG, Swanson MS,Freeman C (2000) Effect of morphineand incision length on bowel functionafter colectomy. Dis Colon Rectum43:163–1687. Miedema BW, Johnson JO (2003)Methods for decreasing postoperativegut dysmotility. Lancet Oncol 4:365–3728. Neudecker J, Schwenk W, Junghans T,Pietsch S, Bohm B, Muller JM (1999)Randomized controlled trial to examinethe influence of thoracic epidural anal-gesia on postoperative ileus after lap-aroscopic sigmoid resection. Br J Surg86:1292–12959. Basse L, Hjort Jakobsen D, BillesbolleP, Werner M, Kehlet H (2000) Aclinical pathway to accelerate recoveryafter colonic resection. Ann Surg232:51–5710. Petros JG, Realica R, Ahmad S, RimmEB, Robillard RJ (1995) Patient-con-trolled analgesia and prolonged ileusafter uncomplicated colectomy. Am JSurg 170:371–37411. Schwenk W, Bohm B, Haasae O,Junghans T, Muller JM (1998) Lap-aroscopic versus conventionalcolorectal resection: a prospective ran-domized study of postoperative ileusand early postoperative feeding. Lan-genbecks Arch Surg 383:49–5512. Bohm B, Milsom JW, Fazio VW(1995) Postoperative intestinal motilityfollowing conventional and laparo-scopic colorectal surgery. Arch Surg130:415–41913. Carli F, Trudel JL, Belliveau P (2001)The effect of intraoperative thoracicepidural anesthesia and postoperativeanalgesia on bowel function after co-lorectal surgery: a prospective,randomized trial. Dis Colon Rectum44:1083–108914. Asao T, Kuwano H, Nakamura J,Morinaga N, Hirayama I, Ide M (2002)Gum chewing enhances early recoveryfrom postoperative ileus after laparo-scopic colectomy. J Am Coll Surg195:30–3215. Taguchi A, Sharma N, Saleem RM,Sessler DI, Carpenter RL, SeyedsadrM, Kurz A (2001) Selective postoper-ative inhibition of gastrointestinal opi-oid receptors. N Engl J Med 345:935–94016. Dorrance HR, Docherty GM, O’DwyerPJ (2000) Effect of surgeon specialtyinterest on patient outcome after po-tentially curative colorectal cancer sur-gery. Dis Colon Rectum 43:492–49817. Smith JAE, King PM, Lane RHS,Thompson MR (2003) Evidence of theeffect of specialization on the manage-ment, surgical outcome and survivalfrom colorectal cancer in Wessex. Br JSurg 90:583–59218. Porter GA, Soskolne CL, YakimetsWW, Newman SC (1998) Surgeon-related factors and outcome in rectalcancer. Ann Surg 227:157–16719. Gillis CR, Hole DJ (1996) Survivaloutcome of care by specialist surgeonsin breast cancer: a study of 3786patients in the west of Scotland. BMJ312:145–14820. McArdle CS, Hole DJ (2004) Influenceof volume and specialization on survi-val following surgery for colorectalcancer. Br J Surg 91:610–617546

The duration of postoperative ileus after elective colectomy is correlated to surgical specialization

http://doc.rero.ch/record/312948/files/384_2005_Article_50.pdf

The duration of postoperative ileus after elective colectomy is correlated to surgical specialization

Abstract

Similar works

Full text

Available Versions

RERO DOC Digital Library