Pain and opioid use after colorectal resection for benign versus malignant disease: A single institution analysis.

BACKGROUND: Studies comparing opioid needs between benign and malignant colorectal diseases are inconclusive. METHODS: Single institution analysis of prospectively maintained colorectal surgery database. Multiple regression analyses done on perioperative numeric pain scores (NPS) and opioids prescribed at discharge. RESULTS: 641 patients in Benign and 276 patients in the Malignant group. Unadjusted comparison revealed significantly higher NPS for the Benign than the Malignant group preoperative and postoperative day 0 (after surgery), 1, 2, and 3 (all p â€‹≤ â€‹0.001). Opioids prescribed at discharge were significantly higher in the Benign group (60.0% vs 51.1%, p â€‹= â€‹0.018). After regression analysis, there was no longer a significant difference in NPS (B â€‹= â€‹0.703, p â€‹= â€‹0.095) and opioids prescribed between groups [OR â€‹= â€‹0.803 (95%CI 0.586, 1.1), p â€‹= â€‹0.173]. CONCLUSIONS: Pain and opioids prescribed at discharge are not significantly different between benign and malignant diseases in an enhanced recovery pain management pathway that maximizes non-opioid multimodal analgesic strategies.

Ureteral Stents Do Not Increase the Risk for Acute Kidney Injury After Colorectal Surgery.

BACKGROUND: Ureteral stents are thought to prevent or help identify ureteral injuries. Studies suggesting that ureteral stents increase the risk of postoperative acute kidney injury show inconsistent conclusions. The large ureteral stenting volume at our institution provided a unique opportunity for granular analysis not previously reported. OBJECTIVE: To determine whether prophylactic ureteral stenting at colorectal surgery increases acute kidney injury. DESIGN: Retrospective analysis of colorectal operations with prophylactic ureteral stents was compared to operations without stents. Adjusted analysis was performed with inverse probability treatment weighting. SETTINGS: Single institution enhanced recovery colorectal surgery service. PATIENTS: Prospective institutional database between July 1, 2018, and December 31, 2021. MAIN OUTCOME MEASURE: The primary outcome was acute kidney injury, defined as increase in creatinine ≥0. 3 mg/dL (definition 1) and 1.5-fold increase in creatinine (definition 2) within 48 hours postoperatively. RESULTS: There were 410 patients in the study population: 310 patients in the stent group and 100 in the no-stent group. There were 8 operative ureteral injuries: 4 (1.29%) in the stent group and 4 (4.0%) in the no-stent group ( p = 0.103). Unadjusted analysis revealed no significant difference in acute kidney injury between groups. After adjustment, there was still no significant difference in acute kidney injury between groups when defined as definition 1 (no-stent 23.76% vs stent 26.19%, p = 0.745) and as definition 2 (no-stent 15.86% vs stent 14.8%, p = 0.867). Subgroup analysis showed that lighted stents were associated with significantly more acute kidney injury than no-stent patients when defined as definition 1 ( p = 0.017) but not when defined as definition 2 ( p = 0.311). LIMITATIONS: Single-institution results may not be generalizable. CONCLUSION: Prophylactic ureteral stenting does not increase the risk of acute kidney injury for patients undergoing enhanced recovery colorectal surgery, although caution and further study may be warranted for lighted stents. Studies further examining contrasting roles of ureter stenting and imaging in open and minimally invasive colorectal surgery are warranted. See Video Abstract. LOS STENTS URETERALES NO AUMENTAN EL RIESGO DE LESIN RENAL AGUDA DESPUS DE LA CIRUGA COLORECTAL: ANTECEDENTES:Se cree que los stents ureterales previenen o ayudan a identificar las lesiones ureterales. Los estudios que sugieren que los stents ureterales aumentan el riesgo de lesión renal aguda post operatoria muestran conclusiones contradictorias. El gran volumen de endoprótesis ureterales en nuestra institución brindó una oportunidad única para el análisis granular que no se informó anteriormente.OBJETIVO:Determinar si la colocación de stent ureteral profiláctico en cirugía colorrectal aumenta el daño renal agudo.DISEÑO:El análisis retrospectivo de operaciones colorrectales con stents ureterales profilácticos se comparó con operaciones sin stents. El análisis ajustado se realizó con ponderación de tratamiento de probabilidad inversa.AJUSTES:Cirugía colorrectal de recuperación mejorada de una sola instituciónPACIENTES:Base de datos institucional prospectiva entre el 01/07/2018 y el 31/12/2021.MEDIDA DE RESULTADO PRINCIPAL:El resultado primario fue la lesión renal aguda definida como un aumento en la creatinina ≥ 0,3 mg/dL (Definición n.° 1) y un aumento de 1,5 veces en la creatinina (Definición n.° 2) dentro de las 48 horas posteriores a la operación.RESULTADOS:Hubo 410 pacientes en la población de estudio: 310 pacientes en el grupo Stent y 100 en el grupo No-Stent. Hubo 8 lesiones ureterales operatorias, 4 (1,29%) en el grupo Stent y 4 (4,0%) en el grupo No-Stent (p = 0,103). El análisis no ajustado no reveló diferencias significativas en la lesión renal aguda entre los grupos. Después del ajuste, todavía no hubo una diferencia significativa en la lesión renal aguda entre los grupos cuando se definió como Definición n.º 1 (sin stent 23,76 % frente a stent 26,19 %, p = 0,745) y por definición n.º 2 (sin stent 15,86 % frente a stent 14,8 %, p = 0,867). El análisis de sub grupos mostró que los stents iluminados se asociaron con una lesión renal aguda significativamente mayor que los pacientes sin stent cuando se definieron como Definición n.º 1 (p = 0,017), pero no cuando se los definió como Definición n.º 2 (p = 0,311).LIMITACIONES:Los resultados de una sola institución pueden no ser generalizables.CONCLUSIÓN:La colocación profiláctica de endoprótesis ureterales no aumenta el riesgo de lesión renal aguda en pacientes que se someten a cirugía colorrectal de recuperación mejorada, aunque es posible que se requiera precaución y estudios adicionales para las endoprótesis iluminadas. Se justifican estudios que examinen más a fondo las funciones contrastantes de la colocación de stents de uréter y las imágenes en la cirugía colorrectal abierta y mínimamente invasiva. (Traducción-Dr. Mauricio Santamaria ).

Early Urinary Catheter Removal After Colectomy for Colovesical Fistula is Not Associated With Increased Postoperative Complications.

BACKGROUND: Management of the bladder defect during colectomy for colovesical fistula (CVF) and recommendations for duration of urinary catheter drainage are inconsistent. This study aimed to determine if urinary catheter drainage duration was associated with postoperative complications. METHODS: Retrospective single institution cohort study of patients undergoing resection for diverticular CVF from 2015 through 2021. Urinary catheter drainage was defined as Early (≤7 days postoperative and then subdivided into 1-2 days, 3-5 days, 6-7 days), and Late (>7 days postoperative). Primary outcome was a composite measure of postoperative bladder leak, surgical site infection-III, sepsis, reoperation, and postoperative length-of-stay ≥7 days. RESULTS: There were 73 patients-64 Early group and 9 Late group. Composite measure between groups (Early 25% vs Late 33.33%, P = .688) was not significantly different. The Late group had more patients with large bladder defects (33.3% vs 7.8%, P = .054), significantly more patients who underwent suture repair (55.6% vs 14.1%, P = .01), and significantly more patients that had an intraoperative pelvic drain (66.7% vs 15.6%, P = .003). After propensity score inverse weighting, the Late group had significantly more cystogram-detected postoperative bladder leaks (P = .002) and ileus (P = .042) than the Early group. There were no bladder leaks or ileus in those who had urinary catheter removal on postoperative days 1-2. CONCLUSIONS: Early urinary catheter removal was associated with no increase in bladder leaks and fewer postoperative complications after definitive management of CVF. Further investigation is required to determine if intraoperative bladder leak testing and postoperative cystograms are useful adjuncts in decision making.

Below-ground competition favors character convergence but not character displacement in root traits.

Character displacement can play a major role in species ecology and evolution; however, research testing whether character displacement can influence the evolution of root traits in plant systems remains scarce in the literature. Here we investigated the potential that character displacement may influence the evolution of root traits using two closely related morning glory species, Ipomoea purpurea and Ipomoea hederacea. We performed a field experiment where we grew the common morning glory, I. purpurea, in the presence and absence of competition from I. hederacea and examined the potential that the process of character displacement could influence the evolution of root traits. We found maternal line variation in root phenotypes and evidence that below-ground competition acts as an agent of selection on these traits. Our test of character displacement, however, showed evidence of character convergence on our measure of root architecture rather than displacement. These results suggest that plants may be constrained by their local environments to express a phenotype that enhances fitness. Therefore, the conditions of the competitive environment experienced by a plant may influence the potential for character convergence or displacement to influence the evolution of root traits.

Belowground Competition Can Influence the Evolution of Root Traits.

Although root traits play a critical role in mediating plant-plant interactions and resource acquisition from the soil environment, research examining whether and how belowground competition can influence the evolution of root traits remains largely unexplored. Here we examine the possibility that root traits may evolve as a target of selection from interspecific competition using Ipomoea purpurea and I. hederacea, two closely related morning glory species that commonly co-occur in the United States, as a model system. We show that belowground competitive interactions between the two species can alter the pattern of selection on root traits in each species. Specifically, competition with I. purpurea changes the pattern of selection on root angle in I. hederacea, and competitive interactions with I. hederacea change the pattern of selection on root size in I. purpurea. However, we did not uncover evidence that intraspecific competition altered the pattern of selection on any root traits within I. hederacea. Overall, our results suggest that belowground competition between closely related species can influence the phenotypic evolution of root traits in natural populations. Our findings provide a microevolutionary perspective of how competitive belowground interactions may impact plant fitness, potentially leading to patterns of plant community structure.