Mohsen Alhashemi, MD, MSc, Julio F Fiore Jr, PhD, Nadia Safa, MDCM, Mohammed Al Mahroos, MD, Nicolo Pecorelli, MD, Gabriele Baldini, MD, Nandini Dendukuri, PhD, Barry L Stein, MD, A. Sender Liberman, MD, Patrick Charlebois, MD, Franco Carli, MD, Liane S Feldman, MD. Mcgill University
INTRODUCTION: Prolonged post-operative ileus (PPOI) is a common complication that results in patient discomfort, prolonged length of stay (LOS) and increased costs. Enhanced-recovery pathways (ERPs) are standardized care plans that include interventions to accelerate gastrointestinal (GI) recovery. The incidence and predictors of PPOI have not been widely studied in this context. The aim of this study is to estimate the incidence and predictors of PPOI in the context of an ERP for colorectal surgery.
METHODS AND PROCEDURES: We analyzed prospectively collected data from an institutional colorectal surgery ERP registry between 2012-2014. Patients with complications predisposing to secondary ileus (bowel obstruction, anastomotic leak, intra-abdominal abscess or bowel perforation) were excluded. Incidence of PPOI was estimated according to a definition adapted from Vather (intolerance of solid food and not passing first flatus or bowel movement on or after post-operative day 4) and compared to other definitions in the literature. Potential risk factors for PPOI were identified from previous studies and their predictive ability was evaluated using Bayesian Model Averaging (BMA), which accounts for model uncertainty by considering all possible models resulting from including or excluding the predictors of interest. Results are presented as posterior effect probability (PEP), which indicates the probability that a particular risk factor is associated with PPOI. The strength of evidence of association was categorized as: no evidence(PEP<50%), weak evidence(50-75%), positive evidence(75-95%), strong evidence(95-99%), and very strong evidence(>99%).
RESULTS: Of the 347 patients, 24 patients with complications that predispose to secondary ileus were excluded, and 323 patients were analyzed (median age 63.5 years, 51% males, 74% laparoscopic, 33% rectal resection). The incidence of PPOI was 19% according to the primary definition, but varied between 11-59% when using other definitions. On BMA analysis, intraoperative blood loss (PEP 99%; very strong evidence), administration of any intravenous opioids in the first 48hours (PEP 94%; strong evidence), post-operative epidural analgesia (PEP 56%; weak evidence), and non-compliance with intra-operative fluid management protocols (3ml/kg/h for laparoscopic and 5ml/kg/hr for open, excluding replacement for blood loss; PEP 55%, weak evidence) were predictors of PPOI.
CONCLUSIONS: The incidence of PPOI after colorectal surgery is high even within an established ERP and varied considerably applying different diagnostic criteria, highlighting the need for a consensus definition. The use of intravenous opioids is a modifiable strong predictor of PPOI within an ERP, while the role of epidural analgesia and intraoperative fluid management should be further evaluated in larger studies.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87795
Program Number: S131
Presentation Session: ERAS Session
Presentation Type: Podium