Presentation Transcript

1. GI Patient Recovery Case:Postoperative Ileus

   Laurence R. Sands, MD, MBA, FACS, FASCRS Professor of Clinical Surgery Chief, Division of Colon and Rectal Surgery University of Miami School of Medicine Attending Surgeon Jackson Memorial Hospital University of Miami Hospitals and Clinics University of Miami Hospital Miami, Florida
2. Faculty Disclosure It is the policy of The France Foundation to ensure balance, independence, objectivity, and scientific rigor in all its sponsored educational activities. All faculty, activity planners, content reviewers, and staff participating in this activity will disclose to the participants any significant financial interest or other relationship with manufacturer(s) of any commercial product(s)/device(s) and/or provider(s) of commercial services included in this educational activity. The intent of this disclosure is not to prevent a person with a relevant financial or other relationship from participating in the activity, but rather to provide participants with information on which they can base their own judgments. The France Foundation has identified and resolved any and all conflicts of interest prior to the release of this activity. Laurence R. Sands, MD, MBA, FACS, FASCRS, has no financial relationships to disclose.
3. Educational Learning Objective Evaluate the evidence for therapeutic options that may improve gastrointestinal recovery postsurgery and integrate these efforts toward supporting overall surgical quality measures
4. The Patient 48-year-old white male Chief complaint Rectal bleeding x 4 months Change in bowel habits
5. History of the Present Illness 6 months of alteration of stool caliber Associated crampy abdominal pain Rectal bleeding x 4 months 10 pound weight loss over 3 months Decreased appetite
6. Past Medical/Surgical History Hypertension Benign prostatic hypertrophy Coronary artery disease No abdominal surgery in the past Repair of right knee meniscal tear 20 years ago
7. Medications Atenolol for hypertension Occasional ibuprofen for joint pain
8. Family History Father with history of colon cancer when he was 65 Underwent surgery with segmental colectomy and postoperative chemotherapy Disease-free more than 5 years after completion of therapy
9. Social History Occasional social drinker Denies tobacco use Denies drug use Works in real estate
10. Plan of Care Patient advised to undergo colonoscopy for history of change in bowel habits, rectal bleeding, abdominal pain, and weight loss CT scan advised after colonoscopy
11. Colonoscopic Findings Multiple colonic polyps 25 to 30 in total Sessile and pedunculated 3 distinct colonic masses Ascending colon Hepatic flexure Transverse colon Rectum clear of polyps Biopsies show multiple tubular adenomas and 3 invasive adenocarcinomas
12. Colon Cancer and Polyps
13. CT Scan Imaging Masses in the colon No evidence of metastatic disease
14. CT Image of Right-Sided Colon Cancer
15. Preoperative Studies Exercise stress test Positive Cardiac catheterization Triple vessel disease CEA level 0.5 (normal)
16. Impression and Plan Attenuated form of familial adenomatous polyposis (FAP) Positive catheterization Need for coronary artery bypass surgery followed by laparoscopic colectomy
17. Surgery 1 month after successful CABG, patient scheduled to undergo laparoscopic total abdominal colectomy with ileorectal anastomosis
18. Preoperative Workup and Support Liquid diet the day prior to surgery Full mechanical bowel preparation GoLYTELY® the day prior to surgery Oral antibiotic bowel preparation Neomycin 1 gm at 7 PM and 1 gm at 11 PM the night prior to surgery Metronidazole 1 gm at 7 PM and 1 gm at 11 PM the night prior to surgery NPO after midnight prior to surgery Preoperative counseling provided
19. In The Operating Room Intravenous antibiotics Ertapenem 1 gm given within 30 minutes of incision DVT prophylaxis SQ heparin 5000 units given General anesthesia induction Positioned in low lying lithotomy with both arms tucked at the side Foley catheter and orogastric tube placed
20. Operating Room Events Laparoscopic total abdominal colectomy performed with ileorectal anastomosis Warmed gas infuser used for insufflation Operative time: 280 minutes Blood loss: 50 ml Urine output: 150 ml Orogastric tube removed at the conclusion of surgery
21. Postoperative Orders To recovery room and then to regular floor Clear liquids ordered once patient is awake and alert in recovery room and able to eat by anesthesia recovery room guidelines PCA morphine ordered for patient use for analgesia
22. Postoperative Recovery POD 1 – out of bed to chair Low urine output Treated with IV fluid bolus and increase IV rate POD 2 – early ambulation encouraged POD 3 – patient complains of severe abdominal pain Mild tachycardia No fever Exam reveals tender and distended abdomen
23. Management of POI NPO Increase IVF for low urine output Labs monitored Electrolytes (Na, K, Cl, HCO3, Ca, Mg, PO4) CBC to look for WBC count Abdominal x-rays Nasogastric tube placement
24. Postoperative Films of POD 3 Flat plate of abdomen shows multiple loops of distended small bowel consistent with postoperative ileus
25. Postoperative Ileus Upright film of abdomen confirms multiple loops of distended small bowel and no air fluid levels suggesting postoperative ileus and not small bowel obstruction
26. POI Management Upon NGT insertion 850 cc bilious material aspirated from stomach Kept on low continuous suction Maintained NGT until bowel function returned Passage of flatus Passage of stool NGT remained present for 7 days Nutritional support given (TPN)
27. Postoperative Course Bowel function returned NGT removed on POD 10 POD 11 Diet resumed with clear liquids POD 12 Low fat, low residue diet started and tolerated POD 13 Discharge home
28. Postoperative Follow-up Pathology revealed 3 adenocarcinomas and multiple 25 tubular adenomas Consistent with attenuated FAP (familial adenomatous polyposis) T3N1 cancer (stage III disease) Referred for medical oncology for postoperative chemotherapy
29. Prolonged Length of Stay Following Laparoscopic Total Abdominal Colectomy What factors may have contributed to the prolonged length of stay in this patient case? What is the impact of postoperative ileus in terms of cost and resource utilization? What strategies might have made a difference in length of stay for this patient?
30. Question Increasing operative time for laparoscopic total abdominal colectomies has been associated with increased postoperative complications, days to resumption of diet, and length of stay. True or False? True False
31. Answer True A study by Scheer et al reported that laparoscopic total abdominal colectomies lasting longer than 270 minutes were associated with more postoperative complications, longer time to resume normal diet, and longer length of stay compared with surgeries of shorter duration
32. Study Links Length of Surgery to Higher Incidence of Postoperative Ileus Retrospective study – all laparoscopic cases 231 right colectomies 210 sigmoid colectomies 46 total abdominal colectomies In total abdominal colectomy group increased operative time linked to Increased postoperative complications Longer postoperative ileus (5 vs 3 days to diet) Longer length of stay (7 vs 5 days) To read more about this study, click here: http://www.ncbi.nlm.nih.gov/pubmed/19966608 Scheer A, et al. Dis Colon Rectum. 2009;52:1746-1752.
33. Operative Time and Laparoscopic Total Abdominal Colectomy Outcomes # † * *P = 0.02 †P = 0.003 #P = 0.045 N = 46 Scheer A, et al. Dis Colon Rectum. 2009;52:1746-1752.
34. Clinical Impact of Postoperative Ileus Increased postoperative pain Increased nausea and vomiting Increased risk of aspiration Prolonged time to regular diet Delayed wound healing Increased risk of malnutrition/catabolism Prolonged time to mobilization Increased pulmonary complications Prolonged hospitalization Increased health care costs Kehlet H, Holte K. Am J Surg. 2001;182(5A suppl):3S-10S. Leslie JB. Ann Pharmacother. 2005;39:1502-1510. Behm B, Stollman N. ClinGastroenterolHepatol. 2003;1:71-80.
35. Hospital Discharge Associated With Recovery of GI Function GI-2 recovery Hospital discharge 25 20 15 Patients (%) 10 5 0 0 1 2 6 7 8 9 10 3 4 5 Postoperative Day GI-2 = Recovery of bowel movement and toleration of solid food Delaney CP, et al. Am J Surg. 2006;191:315-319.
36. Increased Resource Utilization in Colectomy Patients With POI Average cost/admission Primary POI: $15,914 Non-POI: $8,316 For more information on the economic impact of POI, click on the following link: http://www.ncbi.nlm.nih.gov/pubmed/20113944 *P < 0.05 Asgeirsson T, et al. J Am Coll Surg. 2010;210:228-231.
37. Question Which element of an enhanced recovery pathway (ERP) was not included in this patient case, but might have helped to reduce the prolonged length of stay? Patient education and preoperative counseling Opioid-sparing analgesia Early ambulation Prophylactic nasogastric decompression
38. Answer Opioid-sparing analgesia Preoperative counseling was provided to the patient, and early ambulation was encouraged postoperatively. Routine use of abdominal drains and NG tubes postoperatively are not part of enhanced recovery pathways, as their use is associated with the potential for increased complications without benefit for the patient. While opioids are often the analgesic of choice following abdominal surgery, they decrease gastric motility, inhibit small and large intestinal propulsion, and have other GI effects that contribute to the abdominal discomfort associated with POI. Opioid-sparing analgesia following colorectal surgery can help to minimize these negative effects on GI recovery.
39. Factors Expediting Return of Bowel Function Retrospective review of open partial colectomy at single institution Reviewed several factors to determine quicker time to first BM Earlier time to first BM noted with: Early oral intake (76 vs. 134 hours) Preop use of polyethylene glycol (73 vs. 94 hours) Early ambulation (78 vs. 95 hours) Use of NGT (delayed time to first BM by 22 hours) Concluded: routine use of NGT was not beneficial for bowel recovery Sindell S, etal. Am J Surg. 2012;203:644-648.
40. Opioid-Sparing Pain Management A number of strategies have been utilized to decrease systemic opioid utilization following colorectal surgery Nonsteroidal anti-inflammatory drugs (NSAIDs) Epidural analgesia IV lidocaine Wound infiltration with local anesthetics Liposomal long-acting bupivacaine injection Gabapentin Many of the studies investigating opioid-sparing strategies have been conducted in patients following open colorectal surgeries. The benefit for laparoscopic colorectal procedures is less clear
41. Opioid-Sparing Pain Management Ketorolac Prospective, randomized, double-blind study 102 patients undergoing open colorectal resection Morphine (1 mg/mL) + Ketorolac (1.2 mg/mL ) PCA vsMorphine PCA (1 mg/mL) + normal saline PCA PCA settings: 2 mL bolus with 10-minute lockout Total morphine consumption Ketorolac/Morphine = 66 mg Morphine = 81 mg (P < 0.05) Time to first bowel movement Ketorolac/Morphine = 1.8 days Morphine = 2.4 days (P < 0.001) Chen JY, et al. Clin J Pain. 2009;25:485-489.
42. Opioid-Sparing Pain ManagementKetorolac: Laparoscopic Surgery Prospective, randomized, double-blind study (ORAL-CS) 44 patients receiving elective laparoscopic segmental colon resection Ketorolac 30 mg IV every 6 hours x 48 hours vs. placebo All patients received morphine PCA Total morphine consumption: Ketorolac = 33 mg Placebo = 63 mg (P = 0.011) Time to full diet: Ketorolac = 2.5 days Morphine = 3 days (P = 0.033) Length of stay: Ketorolac = 3.6 days Morphine = 4.5 days (NS) For more information on this study, click here: http://www.ncbi.nlm.nih.gov/pubmed/17440782 Schlachta CM, et al. Surg Endosc. 2007;21:2212-2219.
43. Epidural Analgesia vs Parenteral Opioid Analgesia After Colorectal Surgery Systematic review of randomized, controlled trials 16 trials published between 1987 and 2005 14 trials, open surgery; 2 trials, laparoscopic surgery Pain on day 1 (VAS score) WMD – 15 (-19 to -11, P < 0.001) Duration of GI dysfunction WMD – 1.55 days (-2.27 to -0.84, P < 0.001) Length of stay WMD 0.07 days (-0.4 to 0.54, P = 0.76) Marret E, et al. Br J Surg. 2007;94:665-673. WMD: weighted mean difference
44. Opioid-Sparing Pain ManagementIntravenous Lidocaine Meta-analysis; 8 randomized, controlled trials (n = 161 IV lidocaine, n = 159 controls); 6 open surgery trials; 2 laparoscopy Duration of POI Significantly reduced with IV lidocaine WMD -8.36 hr (-13.24 to -3.47) P < 0.001 Length of hospital stay Significantly shorter with IV lidocaine WMD -0.84 days (-1.38 to -0.31) P < 0.002 VAS pain scores at 24 hr Significantly lower with IV lidocaine WMD -5.93 (-9.63 to -2.23) P < 0.002 Marret E, et al. Br J Surgery. 2008;95:1331-1338.
45. Opioid-Sparing Pain ManagementIV Lidocaine–Laparoscopic Colectomy * * * *P < 0.001 To read about the use of IV lidocaine in patients following colorectal surgery, click here. http://www.ncbi.nlm.nih.gov/pubmed/17197840 Kaba A, et al. Anesthesiology. 2007;106:11-18.
46. Enhancing GI Recovery with Peripheral Mu-Opioid Receptor Antagonism Alvimopan (a peripherally acting mu-opioid receptor antagonist) is FDA-approved for accelerating GI recovery following bowel resection with primary anastomosis In patients undergoing bowel resection, alvimopan Accelerated return of bowel function Reduced the time to discharge order written Reduced postoperative ileus-related morbidity Did not reverse postoperative analgesia Benefit of alvimopan uncertain for laparoscopic procedures, with epidural analgesia, or together with NSAIDs Barletta JF, et al. J LaparoendoscopAdvSurg Tech. 2011;21:887-891. Vaughan-Shaw PG, et al. Dis Colon Rectum. 2012;55:611-620.
47. Alvimopan in Laparoscopic Surgery Retrospective case series review at a single community hospital (2007–2010) Before and after introduction of alvimopan to perioperative care pathway for laparoscopic colectomy 101 alvimopan patients vs 64 pre-alvimopan controls Mean length of stay for the alvimopan group was 1.55 days less than control group (2.81 vs 4.36 days, P < 0.0001) POI in alvimopan group was 2% vs 20% in control group (P < 0.0001) Itawi EA, etal.JSLS. 2011;15:492-498.
48. Fast Track Protocols Help Fast track protocol vs traditional care Reduces POI by 43% Decreased LOS by 1.35 days Ward CW. MedsurgNurs. 2012;21:214-220.
49. Summary Postoperative ileus is a real entity with prolonged length of stay and increased morbidity Use of non-narcotics for pain control may reduce postoperative ileus Use of alvimopan may be helpful to reduce postoperative ileus by allowing narcotic use and not affecting bowel function In total abdominal colectomy and longer operations, much consideration for reducing postoperative ileus should be employed