Effects on Postoperative Gastrointestinal Motility After Neuromuscular Blockade Reversal With Sugammadex Versus Neostigmine/Glycopyrrolate in Colorectal Surgery Patients.

BACKGROUND: Neuromuscular blockers (NMBs) used during surgery have historically been reversed with acetylcholinesterase inhibitors and anticholinergic agents, which can slow gastrointestinal motility. Sugammadex (SUG) provides NMB reversal with minimal effects on gastrointestinal motility. OBJECTIVE: The purpose of this study was to determine if SUG for reversal of NMB is associated with decreased time to first bowel movement (BM) following laparoscopic colorectal surgery. METHODS: A retrospective cohort analysis divided 224 patients undergoing laparoscopic colorectal surgeries based on whether they received SUG or a combination of neostigmine and glycopyrrolate (NG) for NMB reversal. The primary outcome was time (in hours) from NMB reversal until first recorded BM. Secondary end points were postoperative ileus, postoperative nausea and vomiting, prevalence of residual NMB, and hospital length of stay. The relationship between NMB reversal agent and outcomes were analyzed using multivariable linear regression and Cox proportional hazards model. RESULTS: There were 128 patients who received NG and 96 who received SUG. Time to first BM was faster in the SUG group by 11.7 hours (P = 0.004). SUG maintained the effect in a multiple regression model (P = 0.012). A Cox Proportional Hazards regression model found 50% increased odds of a BM across time for the SUG group (P = 0.003). No adverse effects were noted. CONCLUSION AND RELEVANCE: This represents the first report demonstrating faster return of BM following colorectal surgery with SUG when compared with NG. Application of these data may add another tool to enhance recovery after colorectal surgery.

[Enhanced recovery after surgery in colorectal surgery]. / La réhabilitation améliorée après chirurgie colorectale.

Enhanced recovery after surgery (ERAS) in colorectal surgery consists of multidisciplinary, multimodal, and patient-centred care. The implementation of pre-, intra-, and post-operative measures mitigates the surgical stress, the inflammatory reaction, and their consequences. The elements of this protocol are evidence-based medicine. This allows improved and accelerated recovery. Consequently, ERAS reduces the incidence of medical complications by 50 %, including fewer infectious complications, and a possible positive impact on survival after oncologic surgery. Hospital length of stay is shortened. There is no contraindication to ERAS, which must be used for all patients undergoing colorectal surgery. Adaptation of the protocol will nevertheless be necessary in the event of urgent surgery.

La réhabilitation améliorée après chirurgie (RAC) colorectale est une prise en charge multidisciplinaire et multimodale, centrée sur le patient. La mise en place de mesures pré-, per- et postopératoires réduit la réponse au stress chirurgical, la réaction inflammatoire et leurs conséquences. Ce protocole de soins, basé sur des preuves scientifiques, permet une récupération améliorée et accélérée. L'incidence des complications médicales est, secondairement, réduite de 50 %. La réhabilitation améliorée se traduit par une diminution significative de la durée d'hospitalisation, une diminution des complications infectieuses et, probablement, par un impact positif sur la survie après chirurgie oncologique. Il n'y a pas de contre-indication à la RAC qui doit donc être proposée à tous les patients devant subir une chirurgie colorectale. Une adaptation du protocole sera néanmoins nécessaire en cas de chirurgie urgente.

Effect of thoracic epidural anaesthesia on serum vascular endothelial growth factor C and cytokines in patients undergoing anaesthesia and surgery for colon cancer.

BACKGROUND: Serum vascular endothelial growth factor-C (VEGF-C), transforming growth factor-ß (TGF-ß), and interleukin (IL)-6 promote angiogenesis and metastases in colon cancer. We hypothesized that patients who received propofol-epidural anaesthesia (PEA) would exhibit decreases in VEGF-C, TGF-ß, and IL-6 and an increase in IL-10 compared with patients who received general anaesthesia (GA). METHODS: Colon cancer surgery patients were randomly assigned to the PEA (n=20) or GA (n=20) group. Serum VEGF-C, TGF-ß, IL-6, and IL-10 levels before surgery and 24 h after surgery were measured. RESULTS: Patients who received PEA showed decreases in VEGF-C [526 (261) vs 834 (304) pg ml(-1), P=0.001], TGF-ß (P=0.027), and IL-6 (P=0.007) and an increase in IL-10 (P=0.001) 24 h after surgery compared with patients subjected to GA. The visual analogue scale scores at rest and during coughing at 2 and 24 h after operation were significantly lower in PEA patients (P<0.05). CONCLUSIONS: PEA reduces serum concentrations of factors associated with angiogenesis during colon cancer surgery. CLINICAL TRIAL REGISTRATION: ChiCTR-TRC-13003146 (www.chictr.org).

Treatment with corticosteroids and the risk of anastomotic leakage following lower gastrointestinal surgery: a literature survey.

AIM: Background Anastomotic leakage is a serious complication in colorectal surgery. Treatment with corticosteroids is known to impair wound healing but their effect on the healing of a colorectal anastomosis remains unclear, and studies have reported conflicting results. Objective The aim of this study was to evaluate the current evidence regarding the effect of corticosteroids on the risk of anastomotic leakage following colorectal surgery. METHOD: Search strategy A systematic review was conducted following a search of PubMed and Embase. Selection criteria Inclusion criteria were studies published in English and involving humans. A minimum cohort of 50 patients was required and anastomoses involving the ileum, colon and rectum were included. Studies that investigated corticosteroids as a risk factor for anastomotic leakage were included regardless of the duration and the dose of corticosteroids. Data Collection and analysis A comparison was conducted between anastomotic leakage in noncorticosteroid- and corticosteroid-treated patients. The main outcome measure was the risk of anastomotic leakage. RESULTS: Twelve studies with a total of 9564 patients were included in the review. In total, 1034 patients received corticosteroids in the preoperative period, and 344 patients were diagnosed with anastomotic leakage, 70 of whom had received corticosteroids. Six of the 12 studies showed an increased risk for anastomotic leakage in the corticosteroid group. Overall, the anastomotic leakage rate was 6.77% (95% CI: 5.48-9.06) in the corticosteroid group and 3.26% (95% CI: 2.94-3.58) in the noncorticosteroid group. CONCLUSION: Caution should be shown in patients scheduled for lower gastrointestinal surgery with anastomosis.

Elderly patients over 70 years benefit from enhanced recovery programme after colorectal surgery as much as younger patients.

AIM OF THE STUDY: Enhanced recovery programme (ERP) reduces length of hospital stay (LOS) and postoperative complications after colorectal surgery. ERP is feasible and effective in elderly patients. We tested the hypothesis of non-inferiority for elderly patients as compared to younger patients with regard to LOS. PATIENTS AND METHODS: The first 302 consecutive patients scheduled for colorectal surgery and prospectively introduced in our audit database were retrospectively analysed. LOS (primary endpoint), postoperative complications, and adherence to the ERP of elderly (≥70 years, n=100) were compared with those of younger patients (n=202). The same ERP was used in all patients. Non-inferiority hypothesis for LOS was tested using the confidence interval method. Secondary endpoints were compared using the Mann-Whitney U and the Chi2 tests. RESULTS: Except for age patients' demographic data were not different in both groups: 53.8 (17-69) vs. 76.8 (70-90) years. The actual LOS were 3.5 [2-7] and 4.0 [3-7] days in the young and elderly group, respectively. The difference in median LOS between the two groups was 0 (95% CI, -0.97-0.97), demonstrating non-inferiority. Although with more risk factors (anaemia, COPD, cardiac disease, and cancer, P<0.05), elderly patients experienced neither more postoperative medical (17.0 vs. 16.3 %) nor surgical (19.0 vs. 22.3 %) complications than young patients. The adherence to protocol was slightly less in elderly (16 [15-18] vs. 17 [16-18], P=0.05). CONCLUSION: Not only ERP is feasible in seniors, but elderly patients benefit from this perioperative care as much as younger patients. CLINICAL TRIALS REGISTRATION: NCT03620851.