Fluid management and vasopressor use during colorectal surgery: the search for the optimal balance.

BACKGROUND: Although it is known that excessive intraoperative fluid and vasopressor agents are detrimental for anastomotic healing, optimal anesthesiology protocols for colorectal surgery are currently lacking. OBJECTIVE: To scrutinize the current hemodynamic practice and vasopressor use and their relation to colorectal anastomotic leakage. DESIGN: A secondary analysis of a previously published prospective observational study: the LekCheck study. STUDY SETTING: Adult patients undergoing a colorectal resection with the creation of a primary anastomosis. OUTCOME MEASURES: Colorectal anastomotic leakage (CAL) within 30 days postoperatively, hospital length of stay and 30-day mortality. RESULTS: Of the 1548 patients, 579 (37%) received vasopressor agents during surgery. Of these, 201 were treated with solely noradrenaline, 349 were treated with phenylephrine, and 29 received ephedrine. CAL rate significantly differed between the patients receiving vasopressor agents during surgery compared to patients without (11.8% vs 6.3%, p < 0.001). CAL was significantly higher in the group receiving phenylephrine compared to noradrenaline (14.3% vs 6%, p < 0.001). Vasopressor agents were used more often in patients treated with Goal Directed Therapy (47% vs 34.6%, p < 0.001). There was a higher mortality rate in patients with vasopressors compared to the group without (2.8% vs 0.4%, p = 0.01, OR 3.8). Mortality was higher in the noradrenaline group compared to the phenylephrine and those without vasopressors (5% vs. 0.4% and 1.7%, respectively, p < 0.001). In multivariable analysis, patients with intraoperative vasopressor agents had an increased risk to develop CAL (OR 2.1, CI 1.3-3.2, p = 0.001). CONCLUSION: The present study contributes to the evidence that intraoperative use of vasopressor agents is associated with a higher rate of CAL. This study helps to create awareness on the (necessity to) use of vasopressor agents in colorectal surgery patients in striving for successful anastomotic wound healing. Future research will be required to balance vasopressor agent dosage in view of colorectal anastomotic leakage.

Prehabilitation for patients with colorectal cancer: a snapshot of current daily practice in Dutch hospitals.

BACKGROUND: Multimodal prehabilitation programmes are increasingly being imbedded in colorectal cancer (CRC) pathways to enhance the patient's recovery after surgery. However, there is no (inter)national consensus on the content or design of such a programme. This study aimed to evaluate the current practice and opinion regarding preoperative screening and prehabilitation for patients undergoing surgery for CRC throughout the Netherlands. METHODS: All regular Dutch hospitals offering colorectal cancer surgery were included. An online survey was sent to one representative colorectal surgeon per hospital. Descriptive statistics were used for analyses. RESULTS: Response rate was 100% (n = 69). Routine preoperative screening of patients with CRC for frailty, diminished nutritional status and anaemia was the standard of care in nearly all Dutch hospitals (97%, 93% and 94%, respectively). Some form of prehabilitation was provided in 46 hospitals (67%) of which more than 80% addressed nutritional status, frailty, physical status and anaemia. All but two of the remaining hospitals were willing to adopt prehabilitation. The majority of the hospitals offered prehabilitation to specific subgroups of patients with CRC, such as the elderly (41%), the frail (71%) or high-risk patients (57%). There was high variability in the setting, design and content of the prehabilitation programmes. CONCLUSIONS: Whereas preoperative screening is sufficiently incorporated in Dutch hospitals, standardised enhancement of the patient's condition in the context of multimodal prehabilitation seems to be challenging. This study presents an overview of current clinical practice in the Netherlands. Uniform clinical prehabilitation guidelines are vital to diminish heterogeneity in programmes and to produce useful data to enable a nationwide implementation of an evidence-based prehabilitation programme.

Implementation of perioperative music in day care surgery.

BACKGROUND: Perioperative music can have beneficial effects on postoperative pain and perioperative opioid requirement. This study aims to assess the implementation feasibility of music in day care surgery through adherence to implementation, as well as its effects. METHODS: This implementation study employed a prospective single-center study design. Perioperative music was implemented as part of standard surgical care during day care surgery procedures. The music intervention consisted of preselected playlists. Primary outcome was adherence to implementation. Barriers and attitudes towards music of patients and perioperative care providers were evaluated. Furthermore, the effects of music were assessed through a matched cohort analysis. This study was registered with the Netherlands Trial Register (NL8213). RESULTS: From January to April 2020, a total of 109 patients received the music intervention and 97 were analyzed after matching to retrospective controls. Adherence rate to the music intervention was 92% preoperatively, 81% intraoperatively, and 86% postoperatively, with 83% of patients satisfied with the preselected music, and 93% finding music to be beneficial to surgical care. All health care providers believed perioperative music to be beneficial (63%) or were neutral (37%) towards its use. Postoperative pain was not significantly different (mean numeric rating scale 0.74; the music intervention group versus 0.68; control group, p = .363). Although not statistically significant, postoperative opioid requirement in the music group was lower (30% versus 40%, p = .132). CONCLUSION: Perioperative music implementation in day care surgery is feasible with high adherence rates, patient satisfaction levels, and positive attitudes of health care providers towards its use.

Risk Nomogram Does Not Predict Anastomotic Leakage After Colon Surgery Accurately: Results of the Multi-center LekCheck Study.

PURPOSE: Anastomotic leakage (AL) is a dreaded complication after colorectal surgery. Preoperatively identifying high-risk patients can help to reduce the incidence of this complication. For this reason, AL risk nomograms have been developed. The objective of this study was to test the AL risk nomogram developed by Frasson, et al. for validity and to identify risk-factors for AL. METHODS: From the international multi-center LekCheck study database, patients who underwent colonic surgery with the formation of an anastomosis were included. Data were prospectively collected between 2016 and 2019 at 14 hospitals. Univariate and multivariable regression analyses, and area under receiver operating characteristic curve analysis (AUROC) were performed. RESULTS: A total of 643 patients were included. The median age was 70 years and 51% were male. The majority underwent surgery for malignancies (80.7%). The overall AL rate was 9.2%. The risk nomogram was not predictive for AL in the population tested (AUROC 0.572). Low preoperative haemoglobin (p = 0.006), intraoperative hypothermia (p = 0.02), contamination of the operative field (p = 0.004), and use of epidural analgesia (p = 0.02) were independent risk-factors for AL. CONCLUSION: The AL risk nomogram could not be validated using the international LekCheck study database. In the future, intraoperative predictive factors for AL, as identified in this study, should also be included in AL risk predictors.

LekCheck: A Prospective Study to Identify Perioperative Modifiable Risk Factors for Anastomotic Leakage in Colorectal Surgery.

OBJECTIVE: To assess potentially modifiable perioperative risk factors for anastomotic leakage in adult patients undergoing colorectal surgery. SUMMARY BACKGROUND DATA: Colorectal anastomotic leakage (CAL) is the single most important denominator of postoperative outcome after colorectal surgery. To lower the risk of CAL, the current research focused on the association of potentially modifiable risk factors, both surgical and anesthesiological. METHODS: A consecutive series of adult patients undergoing colorectal surgery with primary anastomosis was enrolled from January 2016 to December 2018. Fourteen hospitals in Europe and Australia prospectively collected perioperative data by carrying out the LekCheck, a short checklist carried out in the operating theater as a time-out procedure just prior to the creation of the anastomosis to check perioperative values on 1) general condition 2) local perfusion and oxygenation, 3) contamination, and 4) surgery related factors. Univariate and multivariate logistic regression analysis were performed to identify perioperative potentially modifiable risk factors for CAL. RESULTS: There were 1562 patients included in this study. CAL was reported in 132 (8.5%) patients. Low preoperative hemoglobin (OR 5.40, P < 0.001), contamination of the operative field (OR 2.98, P < 0.001), hyperglycemia (OR 2.80, P = 0.003), duration of surgery of more than 3 hours (OR 1.86, P = 0.010), administration of vasopressors (OR 1.80, P = 0.010), inadequate timing of preoperative antibiotic prophylaxis (OR 1.62, P = 0.047), and application of epidural analgesia (OR, 1.81, P = 0. 014) were all associated with CAL. CONCLUSIONS: This study identified 7 perioperative potentially modifiable risk factors for CAL. The results enable the development of a multimodal and multidisciplinary strategy to create an optimal perioperative condition to finally lower CAL rates.

Evaluating the longitudinal effect of colorectal surgery on health-related quality of life in patients with colorectal cancer.

BACKGROUND AND OBJECTIVES: Surgery for colorectal cancer (CRC) negatively affects health-related quality of life (HRQoL). Addressing shortcomings in literature, the purpose of this study was to evaluate the impact of surgery for CRC on the course of HRQoL from baseline up to 2 years after diagnosis. METHODS: In this prospective, population-based study patients with newly diagnosed CRC were included between 2016 and 2019. HRQoL was assessed by the EORTC QLQ-C30 questionnaire over time both between and within subgroups of patients that underwent right-sided colonic, left-sided colonic, and rectal resection using linear mixed model analyses. RESULTS: The study included 415 patients of whom 148 patients underwent right-sided colonic (36%), 147 left-sided colonic (35%), and 120 rectal resection (29%). Overall, HRQoL scores restored to baseline level 1 year after diagnosis. Impact of surgery seems to be more prominent in patients who underwent rectal resection, as they experienced more pain and had worse role and social functioning scores 4 weeks after surgery. Finally, among patients who underwent left-sided and rectal resection, physical functioning did not return to baseline level during follow-up. CONCLUSION: This study shows several differences (between-group and within-group) in HRQoL according to surgery type and offers perspective which patients may need additional support in the care pathway.

Association Between Intraoperative Blood Glucose and Anastomotic Leakage in Colorectal Surgery.

BACKGROUND: Perioperative hyperglycemia is a known risk factor for postoperative complications after colorectal surgery. The aim of this study was to investigate whether intraoperative blood glucose values are associated with colorectal anastomotic leakage in diabetic and non-diabetic patients undergoing colorectal surgery. METHODS: This is an additional analysis of a previously published prospective, observational cohort study (the LekCheck study). Fourteen hospitals in Europe and Australia collected perioperative data. Consecutive adult patients undergoing colorectal surgery with primary anastomosis between 2016 and 2018 were included. From all patients, preoperative diabetic status was known and intraoperative blood glucose was determined just prior to the creation of the anastomosis. The primary outcome was the occurrence of anastomotic leakage within 30 days postoperatively. RESULTS: Of 1474 patients (mean age 68 years), 224 patients (15%) had diabetes mellitus, 737 patients (50%) had intraoperative hyperglycemia (≥126 mg/dL, ≥7.0 mmol/L), and 129 patients (8.8%) developed anastomotic leakage. Patients with intraoperative hyperglycemia had higher anastomotic leakage rates compared to patients with a normal blood glucose level (12% versus 5%, P<0.001). Anastomotic leakage rate did not significantly differ between diabetic and non-diabetic patients (12% versus 8%, P=0.058). Logistic regression analyses showed that higher blood glucose levels were associated with an increasing leakage risk in non-diabetic patients only. CONCLUSION: Incidence and severity of intraoperative hyperglycemia are associated with anastomotic leakage in non-diabetic patients. Whether hyperglycemia is an epiphenomenon, a marker for other risk factors or a potential modifiable risk factor per se for anastomotic leakage requires future research.