Introduction
Aim
Materials and methods
1. Preoperative counseling and patient’s education |
2. No bowel preparation (oral lavage in the case of low rectal resection with TME and defunctioning loop ileostomy) |
3. Preoperative carbohydrate loading (400 ml of Nutricia preOp® 2 h prior surgery) |
4. Antithrombotic prophylaxis (Clexane® 40 mg sc. starting in the evening prior surgery) |
5. Antibiotic prophylaxis (preoperative cefuroxime 1.5 g + metronidazole 0.5 g iv. 30–60 min prior surgery) |
6. Laparoscopic surgery |
7. Balanced intravenous fluid therapy (<2500 ml intravenous fluids during the day of surgery, <150 mmol sodium) |
8. No nasogastric tubes postoperatively |
9. No drains left routinely for colonic resections, one drain placed for <24 h in case of TME |
10. TAP block and standard anesthesia protocol |
11. Avoiding opioids, multimodal analgesia (oral when possible—paracetamol 4 × 1 g, ibuprofen 2 × 200 mg, metamizole 2 × 500 mg or ketoprofen 2 × 100 mg) |
12. Prevention of postoperative nausea and vomiting (PONV) (dexamethasone 8 mg iv., ondansetron 8 mg iv., metoclopramide 10 mg iv.) |
13. Postoperative oxygenation therapy (4–6 l/min) |
14. Early oral feeding (oral nutritional supplement 4 h postoperatively—Nutricia Nutridrink® or Nestlé Impact®, light hospital diet and oral nutritional supplements on the first postoperative day, full hospital diet in the second postoperative day) |
15. Urinary catheter removal on the first postoperative day |
16. Full mobilization on the first postoperative day (getting out of bed, going to toilette, walking along the corridor, at least 4 h out of bed) |
Parameter | All patients | Group 1 (≤4 days) | Group 2 (>4 days) |
p value |
---|---|---|---|---|
Number of patients, n (%) | 143 | 75 (52.4 %) | 68 (47.6 %) | – |
Females, n (%) | 68 (47.6 %) | 39 (52 %) | 29 (42.6 %) | 0.26 |
Males, n (%) | 75 (52.4 %) | 36 (48 %) | 39 (57.4 %) | |
Mean age, years ± SD | 66.8 ± 12.6 | 65.9 ± 12.9 | 67.3 ± 12.3 | 0.35 |
BMI, kg/m2 ± SD | 25.9 ± 4.9 | 26.5 ± 5.3 | 25.2 ± 4.5 | 0.24 |
ASA 1, n (%) | 5 (3.5 %) | 4 (5.3 %) | 1 (1.5 %) | 0.14 |
ASA 2, n (%) | 87 (60.9 %) | 44 (58.7 %) | 43 (63.2 %) | |
ASA 3, n (%) | 47 (32.8 %) | 23 (30.7 %) | 24 (35.3 %) | |
ASA 4, n (%) | 4 (2.8 %) | 4 (5.3 %) | 0 (0 %) | |
Any comorbidity, n (%) | 109 (76.2 %) | 54 (72.0 %) | 55 (80.9 %) | 0.21 |
Cardiovascular, n (%) | 52 (36.4 %) | 25 (33.3 %) | 27 (39.7 %) | 0.92 |
Hypertension, n (%) | 74 (51.7 %) | 39 (52.0 %) | 35 (51.5 %) | 0.95 |
Diabetes, n (%) | 28 (19.6 %) | 15 (20 %) | 13 (19.1 %) | 0.89 |
Pulmonary, n (%) | 21 (14.7 %) | 9 (12.0 %) | 12 (17.6 %) | 0.34 |
Renal, n (%) | 12 (8.4 %) | 7 (9.3 %) | 5 (7.4 %) | 0.67 |
Liver, n (%) | 5 (3.5 %) | 1 (1.3 %) | 4 (5.9 %) | 0.14 |
Distance from the place of residence <50 km, n (%) | 103 (72 %) | 52 (69.3 %) | 51 (75.0 %) | 0.33 |
Distance from the place of residence >50 km, n (%) | 40 (28 %) | 23 (30.1 %) | 17 (25.0 %) | |
Colonic resection, n (%) | 100 (69.9 %) | 56 (74.7 %) | 44 (64.7 %) | 0.19 |
TME, n (%) | 43 (30.1 %) | 19 (25.3 %) | 24 (35.3 %) | 0.50 |
AJCC Stage I, n (%) | 45 (31.5 %) | 27 (36 %) | 18 (26.5 %) | |
AJCC Stage II, n (%) | 49 (34.2 %) | 26 (34.7 %) | 23 (33.8 %) | |
AJCC Stage III, n (%) | 34 (23.8 %) | 16 (21.3 %) | 18 (26.5 %) | |
AJCC Stage IV, n (%) | 15 (10.5 %) | 6 (8 %) | 9 (13.2 %) | |
Mean length of hospital stay, days (range) | 5.5 (2–40) | 2.9 (2–4) | 8.4 (5–40) | – |
Median length of hospital stay, days (IQR) | 4 (3–7) | 3 (2–3) | 7 (5–8) | – |
Mean operative time, min ± SD | 185.1 ± 62.2 | 185.4 ± 51.3 | 184.8 ± 73.8 | 0.49 |
Mean intraoperative blood loss, ml ± SD | 90.2 ± 79.5 | 84.3 ± 74.1 | 97 ± 86.1 | 0.36 |
Conversion, n (%) | 3 (2.1 %) | 0 | 3 (4.4 %) | – |
Results
Parameter | Group 1 (≤4 days) | Group 2 (>4 days) |
p value |
---|---|---|---|
Mechanical bowel preparation, n (%) | 25 (33.3 %) | 36 (52.9 %) | 0.02 |
Preoperative CHO loading, n (%) | 58 (77.3 %) | 37 (54.4 %) | 0.006 |
Balanced fluid therapy, n (%) | 69 (92 %) | 42 (61.8 %) | 0.00002 |
Peritoneal drainage, n (%) | 14 (18.7 %) | 38 (55.9 %) | 0.00001 |
Prolonged (>24 h) catheterization after surgery, n (%) | 5 (6.7 %) | 19 (27.9 %) | 0.0003 |
Stoma formation, n (%) | 8 (10,6 %) | 14 (20.6 %) | 0.10 |
Postoperative use of opioids, n (%) | 26 (34.7 %) | 27 (39.7 %) | 0.40 |
Tolerance of full oral diet in the first postoperative day, n (%) | 58 (77.3 %) | 37 (54.4 %) | 0.005 |
Mobilization on the day of the surgery, n (%) | 74 (98.6 %) | 42 (61.8 %) | 0.00001 |
Complications
Clavien–Dindo classification | Complications | Group 1 (≤4 days) | Group 2 (>4 days) |
p value | ||
---|---|---|---|---|---|---|
III B | Perforation of transverse colon from Veress needle (relaparoscopy, suturing) | 0/14 (0 %) | 3 (4.0 %) | 1/25 (4 %) | 6 (8.8 %) | 0.51 |
Perforation of small intestine (relaparotomy, resection) | 0/14 (0 %) | 1/25 (4 %) | ||||
Peristomal fistula (correction under general anesthesia) | 0/14 (0 %) | 1/25 (4 %) | ||||
Trocar-related abdominal wall bleeding (relaparoscopy) | 1/14 (7 %) | 0/25 (0 %) | ||||
III A | Bleeding from anastomosis suture line (controlled endoscopically) | 2/14 (14 %) | 0/25 (0 %) | |||
Anastomosis leakage (treated with Endo-SPONGE®) | 0/14 (0 %) | 3/25 (12 %) | ||||
II | Intraperitoneal hematoma | 0/14 (0 %) | 1 (1.3 %) | 1/25 (4 %) | 5 (7.3 %) | |
Infectious diarrhea (C. difficile) | 0/14 (0 %) | 1/25 (4 %) | ||||
Pneumonia | 0/14 (0 %) | 1/25 (4 %) | ||||
Urinary tract infection | 1/14 (7 %) | 2/25 (8 %) | ||||
I | Surgical site infection | 3/14 (22 %) | 10 (13.3 %) | 5/25 (20 %) | 14 (20.6 %) | |
Non-infectious diarrhea | 1/14 (7 %) | 0/25 (0 %) | ||||
Postoperative nausea and vomiting | 5/14 (36 %) | 7/25 (28 %) | ||||
Arrhythmia | 1/14 (7 %) | 1/25 (4 %) | ||||
Postoperative confusion | 0/14 (0 %) | 1/25 (4 %) |
Comorbidities
Length of stay | |||||
---|---|---|---|---|---|
All patients | Group 1 (≤4 days) | Group 2 (>4 days) |
p value | ||
Comorbidity | |||||
Any comorbidity | 109 (76.2 %) | 54 (72.0 %) | 55 (80.9 %) | 0.21 | |
Cardiovascular | 52 (36.4 %) | 25 (33.3 %) | 27 (39.7 %) | 0.92 | |
Hypertension | 74 (51.7 %) | 39 (52.0 %) | 35 (51.5 %) | 0.95 | |
Diabetes | 28 (19.6 %) | 15 (20 %) | 13 (19.1 %) | 0.89 | |
Pulmonary | 21 (14.7 %) | 9 (12.0 %) | 12 (17.6 %) | 0.34 | |
Renal | 12 (8.4 %) | 7 (9.3 %) | 5 (7.4 %) | 0.67 | |
Liver | 5 (3.5 %) | 1 (1.3 %) | 4 (5.9 %) | 0.14 | |
Number of comorbidities | |||||
0 | 34 (23.8 %) | 21 (28.0 %) | 13 (19.1 %) | 0.58 | |
1 | 58 (40.5 %) | 27 (36.0 %) | 31 (45.6 %) | ||
2 | 24 (16.8 %) | 13 (17.4 %) | 11 (16.2 %) | ||
3 | 23 (16.1 %) | 12 (16.0 %) | 11 (16.2 %) | ||
4 | 3 (2.1 %) | 1 (1.3 %) | 2 (2.9 %) | ||
5 | 1 (0.7 %) | 1 (1.3 %) | 0 |
Complications | ||||
---|---|---|---|---|
All patients | Without complications | With complications |
p value | |
Parameter | ||||
Any comorbidity | 109 (76.2 %) | 79 (76.0 %) | 30 (76.9 %) | 0.90 |
Cardiovascular | 52 (36.4 %) | 43 (41.3 %) | 9 (23.1 %) | 0.04 |
Hypertension | 74 (51.7 %) | 53 (51.0 %) | 21 (53.8 %) | 0.76 |
Diabetes | 28 (19.6 %) | 20 (19.2 %) | 8 (20.5 %) | 0.86 |
Pulmonary | 21 (14.7 %) | 18 (17.3 %) | 3 (7.7 %) | 0.13 |
Renal | 12 (8.4 %) | 11 (10.6 %) | 1 (2.6 %) | 0.09 |
Liver | 5 (3.5 %) | 4 (3.9 %) | 1 (2.6 %) | 0.70 |
Number of comorbidities | ||||
0 | 34 (23.8 %) | 25 (24.0 %) | 9 (23.1 %) | 0.26 |
1 | 58 (40.5 %) | 37 (35.6 %) | 21 (53.8 %) | |
2 | 24 (16.8 %) | 19 (18.3 %) | 5 (12.8 %) | |
3 | 23 (16.1 %) | 19 (18.3 %) | 4 (10.3 %) | |
4 | 3 (2.1 %) | 3 (2.9 %) | 0 | |
5 | 1 (0.7 %) | 1 (0.9 %) | 0 |
Length of stay
Parameter | Univariate logistic regression | Multivariate logistic regression | ||||
---|---|---|---|---|---|---|
OR | 95 % CI |
p value | OR | 95 % CI |
p value | |
Mechanical bowel preparation | 2.25 | 1.14–4.45 | 0.02 | 1.14 | 0.42–3.11 | 0.79 |
No preoperative CHO loading | 2.75 | 1.32–5.73 | 0.007 | 1.23 | 0.41–3.66 | 0.70 |
Non-balanced fluid therapy | 6.85 | 2.57–18.21 | 0.00015 | 3.87 | 1.02–14.71 | 0.046 |
Peritoneal drainage | 5.62 | 2.62–12.04 | 0.00001 | 2.86 | 1.01–8.14 | 0.048 |
Prolonged (> 24 h) catheterization | 5.57 | 1.92–16.17 | 0.002 | 4.58 | 1.33–15.74 | 0.02 |
Tolerating oral diet on the first postoperative day | 2.77 | 1.33–5.74 | 0.007 | 1.01 | 0.33–3.10 | 0.99 |
Mobilization on the day of surgery | 45.81 | 5.89–356.12 | 0.0003 | 20.74 | 2.25–191.30 | 0.008 |
Postoperative complications | 2.38 | 1.10–5.14 | 0.03 | 2.00 | 0.72–5.59 | 0.18 |
Colon/rectum | 1.61 | 0.78–4.32 | 0.19 | 1.15 | 0.37–3.56 | 0.81 |