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Perioperative Management

Bard C. Cosman, M.D., M.P.H.
VA San Diego Healthcare System

Introduction

This review follows the organization of perioperative care of the colorectal surgical patient from the initial evaluation through discharge after an abdominal operation. I will discuss developments since 1995 (when this topic was last reviewed as an ASCRS Core Subject) in preoperative testing, preoperative preparation and prophylactic maneuvers, and selected topics in postoperative management. Disease-specific perioperative management, such as neoadjuvant and adjuvant therapy for cancer, is specifically excluded from this discussion.

I. Preoperative risk assessment
Elective colorectal surgical operations are usually performed either for cancer or for painful or disabling conditions, in which there is little thought of not operating. In most cases, the decision to operate is made virtually regardless of risk. Because of this, the literature on operative risk reduction is not as central to our field as it is, for example, to vascular surgery. However, some lessons apply in colorectal surgery as well.

The goals of perioperative risk assessment are to identify patient factors that increase perioperative risk, to quantify this risk in order to make decisions about timing of the operation, and to intervene so as to minimize risk. The most common serious complications are cardiac and pulmonary, so this is where operative risk assessment literature focuses.

Colorectal surgeons may now follow detailed guidelines for cardiac evaluation before non-cardiac operations.(1) National cardiology organizations have also published detailed guidelines for the use of exercise stress testing and echocardiography in known or suspected cardiac disease.(2,3) Colorectal patients are commonly in the age group that may have angina pectoris or cardiac valvular disease. Recent guidelines for the management of these diseases are available,(4,5) potentially allowing the surgeon to seek consultation less frequently, while simultaneously acquiring a measure of medicolegal protection.

For patients who have a history of myocardial infarction (MI) or who are at significant cardiac risk, updated versions of Goldman's criteria are helpful in counseling patients, as is the old war-horse of global risk assessment, ASA classification, which still compares favorably with the cardiac-specific risk indices.(6) Risk of new MI is related to the recency of an old MI. This type of risk assessment is more useful for counseling than it is for determining the timing of operation, because cancer patients can rarely wait, and cardiac revascularization prior to a colorectal operation is only an option in benign disease such as recurrent, uncomplicated diverticulitis. Other worthwhile interventions include selective use of beta blockers, control of hypertension, appropriate volume management, and of course good pain control.

Pulmonary complications occur after 25 to 50% of major surgical procedures, when one considers symptomatic atelectasis as a complication. Pulmonary problems are especially frequent when the patient has preexisting lung disease, upper abdominal incisions, or obesity. Stopping smoking, incentive spirometry, and selective use of bronchodilators and antibiotics are helpful. Pulmonary risk assessment is possible but is much less accurate and useful than cardiac risk assessment. Specific tests such as PFTs, ABG, and diffusing capacity are almost never indicated for patients undergoing abdominal operation.(7,8)

II. Preoperative tests
Routine preoperative tests, formerly justified as minimizing operative risk, have themselves been minimized appropriately in recent years. This rational trend has been hastened by externally imposed cost controls. The cardinal rule for preoperative testing is that tests not specifically indicated by the history and physical (H&P) are unnecessary.

Because the most common indications for abdominal colorectal surgery--cancer and diverticulitis--are both associated with bleeding, the preoperative hemoglobin/hematocrit is the last of the preoperative blood tests to be applied routinely. Even this low-cost test is almost certainly overused, because patients with anemia requiring transfusion will be readily identifiable on H&P. While preoperative hemoglobin/hematocrit provides a baseline should bleeding occur postoperatively, it is not clear that having this baseline value is important.(9)

Preoperative electrolytes are indicated in patients taking diuretics, and in some patients with cardiac and renal disease. However, these constitute a minority of candidates for abdominal colorectal operations. Formerly commonplace tests such as renal and hepatic function tests, glucose, PT/PTT, urinalysis, and chest x-ray are contraindicated unless findings on H&P direct one to obtain them.

Electrocardiography is still done in most institutions based on age, with women over 50 and men over 40 getting a routine ECG to serve as a baseline for intraoperative monitoring. ST and T-wave abnormalities may be clues to otherwise unrecognized cardiac disease, but the majority of preoperative ECG information is not used, and it is not clear that age alone is better than a quick H&P survey of cardiovascular risk factors in selecting patients for ECG.(10)

After three decades, CEA continues to be the subject of close examination and lively controversy in the preoperative evaluation and postoperative follow-up of colorectal cancer.(11,12,13) There is some evidence to suggest that CEA should be abandoned (along with all other perioperative tests of equivocal value), but colorectal surgeons continue to order it--most will know of patients who may have benefited--and managed-care companies continue to allow it, perhaps because of litigation concerns.

III. Preoperative transfusion
The threshold for transfusion has increased in recent years, as have non-transfusion options (erythropoietin, autologous blood donation) and public fear of transfusion. Preoperative transfusion should be considered below a hemoglobin of 8 mg/dL, with consideration given to the patient's degree of cardiac disease and the anticipated blood loss (rectal operations will more likely require transfusion than colon operations). Intraoperative transfusion is almost never needed above a hemoglobin of 10 mg/dL, and it is almost always needed below a hemoglobin of 6 mg/dL.(14,15)

Autologous blood donation decreases the rate of allogeneic transfusion but increases the rate of transfusion overall.(16) It is almost never indicated in colorectal surgery and is specifically contraindicated in curative operations for cancer.

IV. Mechanical bowel preparation
The role of ritual in colorectal surgery is no better illustrated than in the hoary tradition of bowel preparation. Bolstered by industry's profit motive and physicians' fear of litigation, this awkward and unproven practice remains universal, despite a handful of prospective studies and a meta-analysis that suggest it is unnecessary and may actually lead to more wound infection.(17) Recent practice guidelines acknowledge this paradox.(18) All types of mechanical preparation occasionally engender serious complications.(19,20,21) The balance remains tipped in favor of bowel preparation by the weight of tradition and by the procedure's intuitive appeal to surgeons and patients alike. This appeal is evident in the popular practice of colonic irrigation for purported health benefits.(22) Moreover, cleansing rituals precede religious and life-cycle events in most cultures, and cleanliness holds a special place in American life.(23)

While it may be imprudent to break taboo and discard bowel preparation entirely, surgeons should be emboldened by recent information to keep the patient with an incomplete or "inadequate" prep on the schedule. Preoperative mechanical bowel preparation is only clearly indicated when intraoperative endoscopy is likely. Among effective oral bowel preparations, the low volume of sodium phosphate makes it better accepted by patients than polyethylene glycol.(24)

V. Antibiotic prophylaxis
It is very clear that an intravenous antibiotic given within two hour before starting an abdominal operation lowers the wound infection rate significantly. If the operation is long (> 4 hours), the antibiotic should be administered intraoperatively as well. The antibiotic should cover enteric gram-negative bacilli and anaerobes, but comprehensiveness of coverage is not important, and a first-generation cephalosporin such as cefazolin is as good as more expensive drugs.(25) Timeliness remains a problem, for which the solution is to have the anesthetist administer the antibiotic in the operating room, rather than ordering it "on call to OR."(26)

American colorectal surgeons almost always give oral antibiotics in addition to intravenous antibiotics, despite the lack of demonstrated benefit from using both routes of administration.(27) Modest cost savings may be obtained by discontinuing the oral antibiotics and using an intravenous cephalosporin alone.

Antibiotic irrigation of the peritoneal cavity is worthless in preventing infection. Postoperative antibiotics, whether for 24 hours, 48 hours, or a few days, add cost but no benefit and should not be ordered.

VI. Thromboembolic prophylaxis
Patients having abdominal colorectal operations are almost all at relatively high risk for deep venous thrombosis and pulmonary embolism, with risk factors including long operation (more than 30 minutes!), advanced age, pelvic operation, lithotomy position, obesity, inflammatory bowel disease, and cancer.(28,29) Sequential compression devices or knee-length graduated compression stockings are used routinely and give significant prophylaxis,(30) but adding either subcutaneous heparin or low-molecular-weight heparin to one of the mechanical measures gives better prophylaxis than either heparin or compression alone.(31) Once-a-day dosing of low-molecular-weight heparins is convenient, but the cost is currently higher than subcutaneous heparin, with no significant increase in efficacy.(32)

Prophylactic measures against deep venous thrombosis and pulmonary embolism are commonly administered only in the hospital. However, the period of heightened risk for DVT after abdominal and pelvic operations extends for about six weeks, and it would be rational to consider sending patients home with some type of prophylaxis.(33) Higher-risk fields such as orthopædic surgery will spearhead the move toward continuing DVT prophylaxis after discharge, and the practice may eventually "trickle down" to colorectal surgery.

VII. Nasogastric tube
Routine postoperative nasogastric suction has been consigned to history. When laparoscopic enthusiasts threw down the gauntlet of short hospital stay after colectomy, traditional surgeons responded by looking critically at their practices.(34) Nasogastric suction was shown to be unnecessary and potentially harmful in the majority of postoperative patients, and concerns about complications from distention (such as incisional hernia) proved unfounded.(35) 5-20% of postoperative patients will demonstrate that they need an NG tube.

VIII. Bladder catheter
There has never been consensus on when during the postoperative period to remove the urinary drainage catheter. Colorectal surgeons have traditionally made a distinction between abdominal operations and pelvic operations (pelvic operation = leave Foley longer), but the number of days ranges widely between individuals. A convincing recent study compared 1-day to 5-day drainage for patients with rectal cancer.(36) The 5-day group undergoing anterior resection had the same rate of urinary retention, but a higher rate of urinary tract infection, than the 1-day group. Those undergoing operation for low rectal cancer (< 5cm from anal verge) and those with lymph node metastases had more urinary retention when the catheter was removed on postoperative day 1. Thus one should remove the Foley catheter after 1 day even in rectal cancer operations (and certainly in abdominal operations), and 5-day drainage makes sense for low and obviously node-positive cancers. An exception is in patients with epidural analgesia, who should keep the Foley until the epidural catheter is removed.

IX. Postoperative nutrition
Responding to claims that laparoscopic operations made early oral feeding (and thus early discharge) possible, surgeons became more aggressive about feeding the postoperative patient by mouth on postoperative day 1 or 2. (37,38) This formerly radical departure has become part of standard practice in recent years and, along with the near-banishment of the nasogastric tube, is the most potent ingredient in today's more efficient hospital course. Early feeding is not for every patient, however, and in one study men had three times the failure rate of women, and early feeding failed in almost half of those who had proctocolectomy or total abdominal colectomy.(39) Indications for parenteral nutrition are either severe preoperative malnutrition or the combination of failure of oral feeding for 5 days and absence of a working enteral catheter.(40)

X. Shortening the postoperative ileus
Several prokinetic agents have been tried recently in an attempt to shorten the postoperative ileus. Erythromycin decreased the time to first flatus but had no effect on other ileus parameters, such as time to solid food or time to first bowel movement.(41) Cisapride yielded a significant 1-day decrease across the board, including length of stay, in a small, provocative study,(42) but accumulating information about ventricular arrhythmias makes cisapride unlikely to be used widely or easily in the future. Other promising prokinetic agents are in the works, (43) but it will be years before a prokinetic agent becomes part of routine postoperative care.

XI. Length of stay management
Standardized perioperative care protocols ("clinical pathways") have sprouted everywhere in recent years as surgeons have moved (or have been moved) toward adoption of best practices, evidence-based care, and cost cutting. As the largest group of abdominal operations that requires substantial hospitalization, colorectal resections constitute a natural subject for clinical pathways. Health care systems first target high-cost, high-complication, stereotyped operations such as coronary bypass grafting and hip replacement for clinical pathway implementation, then they look for similar abdominal operations and routinely choose colectomy. At least in one study, the clinical pathway patients had a shorter length of stay.(44) This likely results from the clinical pathway's codification of modern methods of postoperative care such as early feeding and avoiding nasogastric intubation, rather than from any quality inherent to clinical pathways.

The high-handed and unrealistic approach of managed care caused friction in recent years, as colorectal surgeons challenged the managed-care orthodoxy's view that the "ideal" length of stay was 5 days for colectomy was and 6 days for proctocolectomy or abdominoperineal resection.(45,46) Sensing the need to get their house in order, surgeons eliminated the preoperative overnight hospital stay for bowel preparation that had been a long-held standard.47 On the other end of the hospital course, surgeons and health care systems made extensive and sometimes indiscriminate use of home care services, leading to a dramatic rise in their revenues and impact.48,49

The new frontier in length-of-stay management is probably behavioral, as the patient's activity, diet, and perception of pain are closely tied with his or her expectations, motivation, and self-perception.(50) This suggests a larger role for case managers and ancillary staff in the future, because the surgeons have already done their part.

Conclusion

The index elective colorectal abdominal surgical patient of today may have a preoperative CBC, an EKG, a sodium phosphate bowel prep, and oral and intravenous antibiotics prior to operation. Postoperative care includes no nasogastric tube, antibiotics, or routine blood tests. Early feeding, early ambulation, and at least one method of DVT prophylaxis help avoid complications during the patient's 3- to 6-day hospital stay. For the future, one envisions minimizing or deleting the bowel prep, using either oral or intravenous antibiotics (but not both) preoperatively, immediate postoperative enteral feeding, and two or more methods of DVT prophylaxis, at least one of which continues at home after a 2- to 5-day hospital stay.

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