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Postoperative ileus is common after abdominal surgery, and small clinical studies have reported that intraoperative administration of dexmedetomidine may be associated with improvements in postoperative gastrointestinal function. However, findings have been inconsistent and study samples have been small. Further examination of the effects of intraoperative dexmedetomidine on postoperative gastrointestinal function is needed. To evaluate the effects of intraoperative intravenous dexmedetomidine vs placebo on postoperative gastrointestinal function among older patients undergoing abdominal surgery. This multicenter, double-blind, placebo-controlled randomized clinical trial was conducted at the First Affiliated Hospital of Anhui Medical University in Hefei, China (lead site), and 12 other tertiary hospitals in Anhui Province, China. A total of 808 participants aged 60 years or older who were scheduled to receive abdominal surgery with an expected surgical duration of 1 to 6 hours were enrolled. The study was conducted from August 21, 2018, to December 9, 2019. Dexmedetomidine infusion (a loading dose of 0.5 μg/kg over 15 minutes followed by a maintenance dose of 0.2 μg/kg per hour) or placebo infusion (normal saline) during surgery. The primary outcome was time to first flatus. Secondary outcomes were postoperative gastrointestinal function measured by the I-FEED (intake, feeling nauseated, emesis, physical examination, and duration of symptoms) scoring system, time to first feces, time to first oral feeding, incidence of delirium, pain scores, sleep quality, postoperative nausea and vomiting, hospital costs, and hospital length of stay. Among 808 patients enrolled, 404 were randomized to receive intraoperative dexmedetomidine, and 404 were randomized to receive placebo. In total, 133 patients (60 in the dexmedetomidine group and 73 in the placebo group) were excluded because of protocol deviations, and 675 patients (344 in the dexmedetomidine group and 331 in the placebo group; mean [SD] age, 70.2 [6.1] years; 445 men [65.9%]) were included in the per-protocol analysis. The dexmedetomidine group had a significantly shorter time to first flatus (median, 65 hours [IQR, 48-78 hours] vs 78 hours [62-93 hours], respectively; P < .001), time to first feces (median, 85 hours [IQR, 68-115 hours] vs 98 hours [IQR, 74-121 hours]; P = .001), and hospital length of stay (median, 13 days [IQR, 10-17 days] vs 15 days [IQR, 11-18 days]; P = .005) than the control group. Postoperative gastrointestinal function (as measured by the I-FEED score) and delirium incidence were similar in the dexmedetomidine and control groups (eg, 248 patients [72.1%] vs 254 patients [76.7%], respectively, had I-FEED scores indicating normal postoperative gastrointestinal function; 18 patients [5.2%] vs 12 patients [3.6%] had delirium on postoperative day 3). In this randomized clinical trial, the administration of intraoperative dexmedetomidine reduced the time to first flatus, time to first feces, and length of stay after abdominal surgery. These results suggest that this therapy may be a viable strategy to enhance postoperative recovery of gastrointestinal function among older adults. Chinese Clinical Trial Registry Identifier: ChiCTR1800017232.

Purpose To investigate the feasibility of conducting a rehabilitation program for patients following surgery for abdomino-pelvic cancer. Methods A non-randomised controlled before-and-after study. Patients who had undergone surgery for stage I–III abdomino-pelvic cancer (colorectal, gynaecological or prostate cancer) were recruited. The rehabilitation group ( n  = 84) received an 8-week, bi-weekly education and exercise program conducted by a physiotherapist, exercise physiologist, health psychologist and dietician, supplemented by exercise diaries and telephone coaching sessions. The comparator group ( n  = 104) completed postal questionnaires only. Feasibility measures, functional exercise capacity, muscle strength, physical activity levels, pelvic floor symptoms, anxiety and depression, health-related quality of life (HRQoL) and self-efficacy were measured at baseline (time 1), immediately post-intervention (time 2) and at 6 months post-baseline (time 3) and compared within- and between-groups. Results The consent rate to the rehabilitation program was 24%. Eighty-one percent of the rehabilitation group attended 85–100% of 16 scheduled sessions. Overall satisfaction with the program was 96%. Functional exercise capacity, handgrip strength in males, bowel symptoms, physical activity levels, depression and HRQoL were significantly improved in the rehabilitation group ( p  < 0.05) at time 2. The improvements in all these outcomes were sustained at time 3. The rehabilitation group had significantly improved physical activity levels, depression and HRQoL compared with the comparator group at times 2 and 3 ( p  < 0.05). Conclusion Recruitment to this oncology rehabilitation program was more difficult than expected; however, attendance and patient satisfaction were high. This program had positive effects on several important clinical outcomes in patients following abdomino-pelvic cancer treatment. Trial registration ANZCTR 12614000580673.

Studies that use registry data have demonstrated superior long-term overall survival after curative surgical resection of colon cancer at hospitals where the volume of such surgeries is high. However, because such administrative data lack information on cancer recurrence, the true nature of this relation remains uncertain. To determine whether hospital procedure volume predicts long-term outcomes of colon cancer surgery. Nested cohort study within a randomized clinical trial. Intergroup 0089 national adjuvant colon cancer study conducted between 1988 and 1992. 3161 patients with high-risk stage II and stage III colon cancer. Overall survival and recurrence-free survival, by hospital procedure volume as defined by Medicare claims data. With a median follow-up of 9.4 years, 5-year overall survival significantly differed across tertiles of hospital procedure volume (63.8% for patients who had resection at low-volume hospitals compared with 67.3% at high-volume hospitals; P = 0.04). After adjustment for other predictors of colon cancer outcome, the hazard ratio for overall mortality in patients treated at low-volume centers was 1.16 (95% CI, 1.03 to 1.32). However, the risk for cancer recurrence was not associated with hospital procedure volume. Five-year recurrence-free survival was 63.9% for patients who had resection at low-volume hospitals compared with 63.0% at high-volume hospitals (adjusted hazard ratio, 1.03 [CI, 0.89 to 1.18]). These findings did not materially change after stratification by other potential demographic and clinical predictors of outcome. According to prospectively recorded data from a large clinical trial, patients whose colon cancer was resected at low-volume hospitals experienced a higher risk for long-term mortality; however, this increased mortality was not attributable to differences in colon cancer recurrences.

Introduction Hepatic, pancreatic, and complex biliary (HPB) surgery can be associated with major morbidity and significant mortality. For the past 5 years, the American College of Surgeons–National Surgical Quality Improvement Program (ACS–NSQIP) has gathered robust data on patients undergoing HPB surgery. We sought to use the ACS–NSQIP data to determine which preoperative variables were predictive of adverse outcomes in patients undergoing HPB surgery. Methods Data collected from ACS–NSQIP on patients undergoing hepatic, pancreatic, or complex biliary surgery between 2005 and 2009 were analyzed ( n  = 13,558). Diagnoses and surgical procedures were categorized into 10 and eight groups, respectively. Seventeen preoperative clinical variables were assessed for prediction of 30-day postoperative morbidity and mortality. Multivariate logistic regression was utilized to develop a risk model. Results Of the 13,558 patients who underwent an HPB procedure, 7,321 (54%) had pancreatic, 4,881 (36%) hepatic, and 1,356 (10%) biliary surgery. Overall, 70.3% of patients had a cancer diagnosis. Post-operative complications occurred in 3,850 patients for an overall morbidity of 28.4%. Serious complications occurred in 2,522 (18.6%) patients; 366 patients died for an overall peri-operative mortality of 2.7%. Peri-operative outcome was associated with diagnosis and type of procedure. Hepatic trisectionectomy (5.8%) and total pancreatectomy (5.4%) had the highest 30-day mortality. Of the preoperative variables examined, age >74, dyspnea with moderate exertion, steroid use, prior cardiac procedure, ascites, and pre-operative sepsis were associated with morbidity and mortality (all P  < 0.05). Conclusions While overall morbidity and mortality for HPB surgery are low, peri-operative outcomes are heterogeneous and depend on diagnosis, procedure type, and key clinical factors. By combining these factors, an ACS–NSQIP “HPB Risk Calculator” may be developed in the future to help better risk-stratify patients being considered for complex HPB surgery.

Abdominal adhesions are associated with increased postoperative complications, cost and workload. We performed a systematic review with statistical pooling to estimate the formation rate, distribution and severity of postoperative adhesions in patients undergoing abdominal surgery. A literature search was carried out for all articles reporting on the incidence, distribution and severity of adhesions between January 1990 and July 2011. Twenty-five articles fulfilled the inclusion criteria. The weighted mean formation rate of adhesions after abdominal surgery was 54 % (95 % confidence interval [CI] 40–68 %), and was 66 % (95 % CI 38–94 %) after gastrointestinal surgery, 51 % (95 % CI 40–63 %) after obstetric and gynaecological surgery and 22 % (95 % CI 7–38 %) after urological surgery. The mean overall severity score was 1.11 ± 0.98 according to the Operative Laparoscopy Study Group classification. Laparoscopic surgery reduced the adhesion formation rate by 25 % and decreased the adhesion severity score (laparoscopic; 0.36 ± 0.69 vs. open; 2.14 ± 0.84) for gastrointestinal surgery. Our results demonstrate that the incidence and severity of abdominal adhesions varies between surgical specialties and procedures. An increased awareness of adhesions can help in identifying the underlying mechanisms of adhesion formation and novel therapeutic approaches, while also improving the surgical consent process.

Crohn's disease (CD) management targets mucosal healing on ileocolonoscopy as a treatment goal. We hypothesized that radiologic response is also associated with better long-term outcomes. Small bowel CD patients between 1 January 2002 and 31 October 2014 were identified. All patients had pre-therapy computed tomography enterography (CTE)/magnetic resonance enterography (MRE) with follow-up CTE or MRE after 6 months, or 2 CTE/MREs≥6 months apart while on maintenance therapy. Radiologists characterized inflammation in up to five small bowel lesions per patient. At second CTE/MRE, complete responders had all improved lesions, non-responders had worsening or new lesions, and partial responders had other scenarios. CD-related outcomes of corticosteroid usage, hospitalization, and surgery were assessed using Kaplan-Meier survival analysis and multivariable Cox models. CD patients (n=150), with a median disease duration of 9 years, had 223 inflamed small bowel segments (76 with strictures and 62 with penetrating, non-perianal disease), 49% having ileal distribution. Fifty-five patients (37%) were complete radiologic responders, 39 partial (26%), and 56 non-responders (37%). In multivariable Cox models, complete and partial response decreased risk for steroid usage by over 50% (hazard ratio (HR)s: 0.37 (95% confidence interval (CI), 0.21-0.64); 0.45 (95% CI, 0.26-0.79)), and complete response decreased the risk of subsequent hospitalizations and surgery by over two-thirds (HRs: HR, 0.28 (95% CI, 0.15-0.50); HR, 0.34 (95% CI, 0.18-0.63)). Radiological response to medical therapy is associated with significant reductions in long-term risk of hospitalization, surgery, or corticosteroid usage among small bowel CD patients. These findings suggest the significance of radiological response as a treatment target.

One of the most important aspects of profiling healthcare providers or services is constructing a model that is flexible enough to allow for random variation. At the same time, we wish to identify those institutions that clearly deviate from the usual standard of care. Here, we propose a hierarchical Bayes model to study the choice of surgical procedure for rectal cancer using data previously analysed by Simons et al.1 Using hospitals as random effects, we construct a computationally simple graphical method for determining hospitals that are outliers; that is, they differ significantly from other hospitals of the same type in terms of surgical choice.

Re-laparotomy is one of the causes of morbidity and mortality among patients who have had abdominal surgery. Due to the unavailability of laparoscopic surgery in the region, laparotomy remains the standard treatment. As a result, re-laparotomy is commonly performed, significantly increasing the labor load, financial costs, and the risks of morbidity and mortality for patients. The aim of this study is to evaluate the prevalence and factors associated with re-laparotomy procedures, in order to better understand their impact on patient health and healthcare resources. A retrospective cross-sectional study was conducted on patients who underwent gastrointestinal procedures in a hospital in Ethiopia between September 2020 and August 2022. The association between independent variables with re-laparotomy (dependent variable) was analyzed using bi-variate and multivariate logistic regression. Those variables that had a p-value of less than 0.2 were put into a multivariate analysis. The strength of the association was displayed using crude and adjusted odds ratios with a 95% confidence interval. P-values less than 0.05 were used to determine statistical significance. A total of 1276 charts were reviewed, and 127 (10%) of those were found to have re-laparotomy. A greater proportion of re-laparotomy was associated with the occurrence of prior abdominal surgery (AOR = 67.94, 95% CI: 39.07, 118.13), the existence of ischemic bowel during surgery (AOR = 4.36, 95% CI: 2.10, 9.02), and the intraoperative use of inotropic/vasopressor medications (AOR = 7.03, 95% CI: 2.52, 19.59). The prevalence of re-laparotomy was found to be 10% which is higher compared with some previous reports. Prior abdominal surgery, ischemic bowel presence during surgery, and the use of inotropic/vasopressor drugs intra-operatively were all found to be risk factors for re-laparotomy.

Background Endoscopic management of leaks/fistulas after laparoscopic sleeve gastrectomy (LSG) is gaining popularity in the bariatric surgery. Objectives This study aimed to review the efficacy and safety of over-the-scope-clip (OTSC) system in endoscopic closure of post-LSG leak/fistula. Methods PubMed/Medline and major journals of the field were systematically reviewed for studies on endoscopic closure of post-LSG leaks/fistula by means of the OTSC system. Results A total of ten eligible studies including 195 patients with post-LSG leaks/fistula were identified. The time between LSG and leak/fistula ranged from 1 day to 803 days. Most of the leaks/fistula were located at the proximal staple line, and they sized from 3 to 20 mm. Time between leak diagnosis and OTSC clipping ranged from 0 to 271 days. Thirty-three out of 53 patients (63.5%) required one clip for closure of the lesion. Regarding the OTSC-related complications, a leak occurred in five patients (9.3%) and OTSC migration, stenosis, and tear each in one patient (1.8%). Of the 73 patients with post-LSG leak treated with OTSC, 63 patients had an overall successful closure (86.3%). Conclusion OTSC system is a promising endoscopic approach for management of post-LSG leaks in appropriately selected patients. Unfortunately, most studies are series with a small sample size, short-term follow-up, and mixed data of concomitant procedures with OTSC. Further studies should distinguish the net efficacy of the OTSC system from other concomitant procedures in treatment of post-LSG leak.

BACKGROUND:Increasing surgical access to previously underserved populations in the United States may require a major expansion of the use of operating rooms on weekends to take advantage of unused capacity. Although the so-called weekend effect for surgery has been described in other countries, it is unknown whether US patients undergoing moderate-to-high risk surgery on weekends are more likely to experience worse outcomes than patients undergoing surgery on weekdays. OBJECTIVE:The aim of this study was to determine whether patients undergoing surgery on weekends are more likely to die or experience a major complication compared with patients undergoing surgery on a weekday. RESEARCH DESIGN:Using all-payer data, we conducted a retrospective cohort study of 305,853 patients undergoing isolated coronary artery bypass graft surgery, colorectal surgery, open repair of abdominal aortic aneurysm, endovascular repair of abdominal aortic aneurysm, and lower extremity revascularization. We compared in-hospital mortality and major complications for weekday versus weekend surgery using multivariable logistic regression analysis. RESULTS:After controlling for patient risk and surgery type, weekend elective surgery [adjusted odds ratio (AOR)=3.18; 95% confidence interval (CI), 2.26–4.49; P<0.001] and weekend urgent surgery (AOR=2.11; 95% CI, 1.68–2.66; P<0.001) were associated with a higher risk of death compared with weekday surgery. Weekend elective (AOR=1.58; 95% CI, 1.29–1.93; P<0.001) and weekend urgent surgery (AOR=1.61; 95% CI, 1.42–1.82; P<0.001) were also associated with a higher risk of major complications compared with weekday surgery. CONCLUSIONS:Patients undergoing nonemergent major cardiac and noncardiac surgery on the weekends have a clinically significantly increased risk of death and major complications compared with patients undergoing surgery on weekdays. These findings should prompt decision makers to seek to better understand factors, such physician and nurse staffing, which may contribute to the weekend effect.