Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_927_Библиотеки_им_академика_М_И_Перельмана.pdf
COMPLICATIONS 431
MINIMIZING RISK ASSOCIATED WITH IMMUNOSUPPRESSION
Steroids
Chronic steroid use resulting from rheumatic, pulmonary, or inammatory bowel diseases is particularly challenging. In addition to several adverse eects, including osteoporosis, diabetes, and glaucoma,
high doses of steroids have detrimental eects on tissue integrity.
A meta-analysis of seven studies on postoperative complications
and steroid use in persons with inammatory bowel disease (IBD)
included more than 1500 patients and demonstrated an OR of 1.41
(95% CI, 1.08 to 1.87) for all postoperative complications, including
wound breakdown, anastomotic leak, and infectious complications
in the steroid group. In a German study of more than 650 CD anastomoses, the only factor signicantly associated with overall anastomotic complication rate on multivariate analysis was steroid use.
us, ideally, steroids should be tapered preoperatively if possible.
When tapering is not possible, a diverting stoma should be considered to protect the downstream anastomosis. Patients taking steroids
on a long-term basis may require perioperative stress dosages that
are tapered postoperatively to their baseline levels within 3 to 5 days.
However, recent studies have suggested that perioperative stress steroids are overused. To determine how readily steroids can be totally
discontinued in the chronic user, intrinsic adrenal function can be
estimated using a cosyntropin test. is test should be considered
especially in septic patients who use steroids, who require maximization of their immune function to ght infection.
Diabetes
Diabetes mellitus, both insulin-dependent and non–insulindependent types, is a risk factor for postoperative complications,
particularly surgical site infections. e risk of infection rises with
increasing glucose levels. e American Diabetes Association recommends maintaining blood glucose levels below 200 mg/dL to
minimize surgical site infections, which may require the institution
of a perioperative insulin sliding scale for both insulin-dependent
and non–insulin-dependent diabetics who are fasting perioperatively and unable to take their oral hypoglycemics. e target glucose level for patients on an insulin sliding scale is between 140
and 180 mg/dL as recommended by the American Association of
Clinical Endocrinologists and American Diabetes Association
Consensus Statement on Inpatient Glycemic Control. Additionally,
glycosylated hemoglobin (HbA1c), which is indicative of long-term
(90 to 120 day) glycemic control, has been thoroughly studied as a
predictor of poor outcomes in orthopedic, bariatric, and plastic surgery but is less studied in colorectal surgery. Gustafsson’s study of
120 diabetic patients undergoing colorectal surgery demonstrated
that higher preoperative HbA1c levels correlated with higher postoperative blood glucose levels and increased complications. e
HbA1c level should be measured during the preoperative visit for
elective cases. If the level is high, surgery should be postponed until
better control is achieved. Additionally, the risks associated with
secondary organ eects of the diabetes should be evaluated. ese
risks include the possibility of silent myocardial disease, PVD, and
chronic renal failure.
Chemoradiotherapy
Preoperative or neoadjuvant chemotherapy and/or radiotherapy aims
to decrease tumor size in persons with colorectal cancer to allow for
a more complete surgical resection and sphincter-sparing surgery in
persons with tumors located close to the sphincters. Although there
is an increased risk of long-term adverse eects such as impaired
bowel function, incontinence, sexual dysfunction, and pelvic fractures in patients with rectal cancer who have undergone preoperative
irradiation, most studies show no dierence in rates of intraoperative or immediately postoperative complications. However, more
frequent acute hospital admissions for bowel obstruction, abdominal
pain, nausea, and infections (of varying severity) both during radiation therapy and within 6 months aer completion of treatment, as
well as increased rates of venous thromboembolism, bowel obstruction, and stula formation, have been demonstrated.
Chemotherapy impairs immunity and increases the risk of perioperative infection of any type, including overwhelming systemic sepsis. Collaboration with the treating oncologist is recommended, and
colorectal surgery should be delayed until sucient time has passed
for the recovery of the immune system, which is commonly believed
to be at least 6 weeks. When emergency surgery is performed for a
patient undergoing chemotherapy, the white blood cell count should
be carefully monitored, intravenous antibiotics should be administered, and a low suspicion for infection should be maintained. Neutropenia is an indication to delay elective procedures. An absolute
neutrophil level less than 1000/μL is indicative of neutropenia, with
levels less than 500/μL indicating severe, life-threatening neutropenia. Several case studies of neutropenic patients who have required
emergency abdominal surgery have demonstrated a major postoperative complication rate of 50% and a 30-day postoperative mortality rate of more than 30%. ese patients require broad-spectrum
antibiotic coverage, with the consideration of antifungal treatment. If
surgery cannot be avoided in the neutropenic patient, frequent monitoring for clinical signs of infection is key because white blood cell
elevation cannot be relied upon to reect infection. All indwelling
catheters should be removed as soon as possible, and close collaboration with colleagues in oncology/hematology is recommended. Few
guidelines address perioperative administration of granulocyte colony-stimulating factor (G-CSF) in the neutropenic surgical patient.
G-CSF stimulates the production of neutrophils from progenitor
cells and is recommended in patients at high risk for sepsis, including
those with open wounds. Intravenous administration of G-CSF can
cause headaches, rash, nausea, and diarrhea.
Bevacizumab is an antiangiogenic drug used in the treatment of
metastatic colorectal cancer and in some breast, lung, and ovarian
cancers and glioblastomas. However, use of bevacizumab has been
associated with multiple postoperative complications, including
bleeding, wound dehiscence, and poor wound healing. In colorectal surgery in particular it has been associated with increased risk
of pelvic sepsis and colonic anastomotic leaks. us a defunctioning
stoma should be considered, particularly if surgery is not able to be
postponed beyond the recommended 6 weeks aer the last dose of
the drug. Ideally, the drug can be restarted 28 days aer surgery to
reduce the likelihood of late surgical morbidity, particularly in relation to wound healing.
Chronic radiation enteritis is a distinct entity that most commonly
presents between 18 months and 5 years aer radiation treatment but
also can be present several years aer the last dose of radiation. It is
most commonly seen aer treatment for gynecologic, prostate, and
rectal tumors. Approximately a third of these patients require surgery
for subsequent enteritis, with this probability correlating with dosage. Patients who have been exposed to pelvic radiation are at risk for
late strictures and rectal or vaginal bleeding. e risk of anastomotic
leak aer resection of the chronically damaged tissue is unclear, with
some studies nding no dierence between irradiated and nonirradiated patients and others nding anastomotic complications only in
irradiated patients. Acute radiation injury usually causes bowel wall
edema and can precipitate obstruction. is edema usually resolves
when radiation stops, and bowel rest and nasogastric decompression
are started. Preoperative preparation oen involves oral antibiotics to
treat bacterial overgrowth, even in cases of small bowel strictures. It is
important to recognize that the pathophysiology of radiation enteritis relates to small vessel obliteration with resultant tissue ischemia,
and thus surgery involves meticulous technique. Stricturoplasty is
ColoreCtal Surgery in the high-riSk Patient432
not advised, but rather resection and anastomosis with care taken
to anastomose only healthy tissue. e use of the omentum to wrap
or separate one or more anastomoses from adjacent organs to avoid
a stula is recommended, and creation of a temporary protecting
stoma is wise.
MINIMIZING RISK ASSOCIATED WITH MALNUTRITION
Signicant nutritional compromise can worsen perioperative morbidity. Malnutrition is a potentially signicant problem in two particular classes of patients undergoing colorectal surgery: those with
colorectal cancer and those with IBD. Patients with colorectal cancer, particularly those with late stage, metastatic disease, can suer
from the cachexia of malignancy and compromised intake due to
partial obstruction or dysmotility. Patients with CD oen experience malnutrition because of semi-obstructing inamed segments of
diseased bowel, as well as previous multiple small bowel resections
leading to a short gut. Additionally, these patients experience nutrient loss resulting from frequent diarrhea, high-output ileostomies,
and losses through enteric stulae. Factors used to assess nutritional
state include serum albumin, transferrin and prealbumin, percentage
of total body weight lost, and triceps skinfold thickness (as a measure of fat stores). Such factors are included in the Prognostic Nutritional Index, a tool designed to predict complications, mortality, and
postoperative sepsis (Table 81-6). Generally, an albumin level below
3.0 g/dL and a serum transferrin level less than 170 mg/dL indicate
moderately severe malnutrition and an increased likelihood of poor
outcomes. Buzby etal developed a formula using Prognostic Nutritional Index parameters to calculate the linear risk of postoperative
morbidity or mortality aer gastrointestinal surgery (see Table81-6).
is index and formula are nonspecic and predict complications in
general, not serious versus nonserious complications.
Patient optimization with several days of total parenteral nutrition
(TPN) before major colonic surgery is warranted in malnourished
TABLE 81-6: Prognostic Nutritional Index
Parameters and Increased Risk of Complications
Overall Increased Risk
Poor
Parameter
Delayed hypersensi-
tivity in response
Prognosticator
>5 mm induration
response
to 0.1 mL of 1of
3 subcutaneously
administered
antigens (mumps,
Candida albicans,
and streptokinase/
Streptodornase)
Albumin <3.0 g/dL 2.5×
Transferrin level <220 mg/dL 5×
Buzby etal developed a formula using the Prognostic Nutritional Index
(PNI) parameters to calculate the risk of a complication occurring. Risk
(percent) = 158 − 16 (serum albumin g/100 mL) −0.78 (Triceps skinfold,
mm) − 0.20 (serum transferrin g/100 mL) − 5.8 (delayed hypersensitivity,
0 = none, 1 = induration <5 mm in response to 0.1 mL of 1 of 3 subcutaneously administered antigens mumps, Candida albicans, and streptokinase/
Streptodornase and 2 = >5 mm induration). Low risk is suggested by a PNI
score of <40. Intermediate and high risk are suggested by scores of 40-49 and
≥50, respectively.
of a Postoperative
Complication
2.5×
patients. However, this optimization is not possible in emergencies, in which case postoperative nutritional supplementation must
be administered. When treating malnutrition, the underlying cause
must be ascertained (e.g., lack of caloric intake, lack of absorption,
and increased losses/catabolism). Enteral feeding with a nasogastric
tube and high-protein and high-calorie feedings are best in cases in
which the patient is not eating but has an intact and patent gastrointestinal tract. is option should be kept in mind especially during
surgery, because surgical placement of a gastrointestinal or gastrojejunal feeding tube can improve and simplify postoperative management immeasurably, especially in the critically ill patient. Similarly,
malnutrition resulting from an obstructing cancer may be improved
by the creation of a diverting stoma prior to resection so the patient
can resume an oral diet.
TPN is best used in cases of short gut or other intrinsic intestinal
disease. When it is known that a patient will be without a regular
oral diet for more than 5 to 7 days, TPN supplemented with lowresidue oral supplements is optimal to maintain nutrition and the
integrity and defensive barrier function of the intestinal epithelium.
When nutritional requirements are excessive because of disease such
as medically unresponsive ulcerative colitis or a CD phlegmon, TPN
will not replace the ongoing loss of blood, albumin, and other proteins. In such cases, prompt surgical resection is required or further
nutritional deterioration will occur.
MINIMIZING RISK ASSOCIATED WITH HEPATIC DISEASE
Hepatic failure is a signicant risk factor for colorectal surgery. Mortality risk is commonly assessed using the Child-Pugh Classication.
Each parameter (serum bilirubin, serum albumin, international normalized ratio, ascites, and hepatic encephalopathy) is given a number
from 1 to 3 based on severity. e sum of these numbers correlates
with approximate mortality rate. Modied bilirubin scores have
been determined for patients with the primary sclerosing cholangitis
found in association with IBD.
e Model for End-Stage Liver Disease score uses some of the
same parameters as the Child-Pugh Classication to create a formula
to predict survival (Model for End-Stage Liver Disease = 3.78[Ln
serum bilirubin (mg/dL)] + 11.2[Ln international normalized ratio]
+ 9.57[Ln serum creatinine (mg/dL)] + 6.43) (Table 81-7). is scor-
ing system was developed for use in patients undergoing transjugular
intrahepatic portosystemic shunt procedures to predict the odds of
death within 3 months of surgery. It is now more commonly used
to determine prognosis in patients awaiting liver transplantation.
TABLE 81-7: Model for End-Stage Liver Disease
Scoring Systems for Hepatic Disease Values and
Risk of 3-Month Overall Mortality
MELD Score 3-Month Mortality (%)
≥40 71
30-39 53
20-29 20
10-19 6
≤9 2
e Model for End-Stage Liver Disease (MELD) score is not a scoring system
to determine risk of surgical morbidity or mortality. However, it is used in
surgical situations to give a general assessment of a patient’s liver status.
MELD = 3.78[Ln serum bilirubin (mg/dL)] + 11.2[Ln international normalized ratio] + 9.57[Ln serum creatinine (mg/dL)] + 6.43).
COMPLICATIONS 433
Although the calculated survival rate is independent of surgery and
thus does not reect surgical morbidity or mortality, it can be used
in surgical situations to give a general impression of a patient’s liver
status.
e perioperative care of the cirrhotic patient is a big undertaking requiring careful management of volume, coagulation, and
nutritional status. Performing a colectomy with anastomosis in such
patients can result in peritoneal sepsis secondary to contaminated
ascites, whereas the creation of a stoma can also lead to a leak of
ascites, or peristomal varices. To avoid an ascites leaking around a
stoma, a Jackson-Pratt (JP) drain should be placed intraoperatively
at a remote site that subsequently can be easily bagged aer removal
(aer the stoma has healed). Colorectal surgery in the severely cirrhotic patient should be limited to treating critical life-threatening or
malignant disease.
MINIMIZING RISK ASSOCIATED WITH RENAL DISEASE
Impaired renal function is an independent risk factor for adverse
postoperative cardiovascular outcomes, including stroke, myocardial
infarction, and the worsening of heart failure. Such impaired renal
function can be worsened by the use of contrast material for radiologic investigations and hypotension resulting from perioperative
blood or uid loss. Renal function is primarily assessed using serum
creatinine measurements. Careful uid management and the avoidance of nephrotoxic analgesics and antibiotics (intravenous contrast
material, nonsteroidal antiinammatory drugs, aminoglycoside antibiotics, and angiotensin-converting enzyme inhibitors) are key in
these patients.
MINIMIZING RISK IN MORBIDLY OBESE PATIENTS
Obesity rates are increasing worldwide. e physiologic state of being
overweight or obese has been suggested to be a low-grade inammatory state and has been associated with the development of autoimmune diseases, a more severe phenotype in IBD, and increased
postoperative complications aer colorectal and other surgery.
Perioperative morbidities directly correlated with body mass index
include cardiac complications, venous thromboembolism, intraabdominal collections, wound infections, the need for perioperative
blood transfusions, anastomotic leak, and death. Obese patients also
have longer operative times, which are associated with an increased
risk of pulmonary complications. Higher intra-abdominal pressures
during pneumoperitoneum for laparoscopy have been observed in
morbidly obese patients, leading to negative eects on venous stasis,
portal venous blood ow, airway pressure, cardiac function, urinary output, and respiratory compliance. Additionally, in an interesting Korean study of 171 resectable colorectal cancers in patients
with high visceral/subcutaneous fat ratios, these patients had a signicantly lower cumulative disease-free survival rate compared with
patients who had a low ratio. Because of these increased risks, venous
thromboembolism prophylaxis including early mobilization, chest
physiotherapy, and careful attention to wound care, including laparoscopic techniques to decrease wound size, should be undertaken
in this cohort.
S u g g e S t e d R e a d i n g
Benoist S, Panis Y, Alves A, Valleur P. Impact of obesity on surgical outcomes
aer colorectal resection. Am J Surg. 2000;179(4):275–281.
Bilimoria KY, Liu Y, Paruch JL, etal. Development and evaluation of the univer-
sal ACS NSQIP surgical risk calculator: a decision aid and informed consent
tool for patients and surgeons. J Am Coll Surg. 2013;217(5):833–842.
Gustafsson UO, orell A, Soop M, et al. Haemoglobin A1c as a predictor
of postoperative hyperglycaemia and complications aer major colorectal
surgery. Br J Surg. 2009;96(11):1358–1364.
Koltun WA, McKenna KJ, Rung G. Awake epidural anesthesia is eective and
safe in the high-risk colectomy patient. Dis Colon Rectum. 1994;37(12):
1236–1241.
Kouroukis CT, Chia S, Verma S, etal. Canadian supportive care recommen-
dations for the management of neutropenia in patients with cancer. Curr
Oncol. 2008;15(1):9–23.
Louwers L, Schnickel G, Rubinfeld I. Use of a simplied frailty index to pre-
dict Clavien 4 complications and mortality aer hepatectomy: analysis of
the National Surgical Quality Improvement Project database. Am J Surg.
2016;211(6):1071–1076.
Malinchoc M, Kamath PS, Gordon FD, etal. A model to predict poor survival
in patients undergoing transjugular intrahepatic portosystemic shunts.
Hepatology. 2000;31(4):864–871.
Mullen JL, Gertner MH, Buzby GP, etal. Implications of malnutrition in the
surgical patient. Arch Surg. 1979;114(2):121–125.
Ondrula DP, Nelson RL, Prasad ML, etal. Multifactorial index of preoperative
risk factors in colon resections. Dis Colon Rectum. 1992;35(2):117–122.
Poldermans D, Bax JJ, Boersma E, etal. Guidelines for pre-operative cardiac
risk assessment and perioperative cardiac management in non-cardiac
surgery: the Task Force for Preoperative Cardiac Risk Assessment and
Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society
of Anaesthesiology (ESA). Eur J Anaesthesiol. 2010;27(2):92–137.
Sehgal R, Berg A, Figueroa R, etal. Risk factors for surgical site infections aer
colorectal resection in diabetic patients. J Am Coll Surg. 2011;212(1):29–34.
Tekk is PP, Prytherch DR, Kocher HM, etal. Development of a dedicated risk-
adjustment scoring system for colorectal surgery (colorectal POSSUM).
Br J Surg. 2004;91(9):1174–1182.
Zaghiyan K, Melmed GY, Berel D, etal. A prospective, randomized, nonin-
feriority trial of steroid dosing aer major colorectal surgery. Ann Surg.
2014;259(1):32–37.
R P
S
Jon Worsey and Victor Fazio
INTRODUCTION
Reoperative pelvic surgery is one of the most dicult challenges a
colon and rectal surgeon can face. Anatomic, postsurgical, and disease-specic factors combine to present unique challenges with signicant potential for major morbidity and even mortality. is is not
the occasion for hubris or poor judgment. However, with a thorough
understanding of normal and postsurgical anatomy, experience in
operating in the pelvis, appropriate planning, sound judgment, and
a methodical team approach, a successful outcome may be achieved.
ANATOMIC FACTORS
e pelvis is a bony cavity with limited visibility and access. e limitations are due to multiple factors: its bony walls, its angulation, the
narrowness and depth of the male pelvis, and patient obesity. e
pelvis contains complex gastrointestinal, urologic, gynecologic, and
neurovascular structures that are in danger during pelvic surgery,
and especially during reoperative pelvic surgery. Particularly vulnerable are the ureters, the presacral veins, and the pelvic nerves.
The Ureters
e distal ureter is a retroperitoneal structure that enters the pelvis
by passing over the bifurcation of the common iliac artery. It then
runs along the lateral pelvic sidewall beneath the investing parietal
pelvic fascia before turning upward and medially to enter the trigone
of the bladder.
into the pelvis. Pelvic parasympathetic nerves join them to form the
pelvic autonomic nerve plexus. Nerves from this plexus pass anteriorly and medially to the bladder, urinary sphincter, rectum, and
genital organs, separated from the anterior rectum by Denonvilliers
fascia, which may be seen as a discrete white layer in some cases.
POSTOPERATIVE CHANGES IN THE PELVIS
Pelvic surgery can cause a variety of changes to pelvic anatomy. Small
bowel may fall into the pelvis and become adherent, sometimes in
a dense manner, and must be mobilized before any pelvic work can
begin. A previously mobilized rectum sinks deep into the pelvis and
oen will become xed to its surroundings and dicult to mobilize.
A short rectal stump may retract down to the pelvic oor and not
be apparent at all. Similarly, a mobilized ureter can be in a markedly ectopic location, oen migrating medially and being fused to
intestine or its mesentery, where it is at risk of injury. e usually
well-dened fascial planes are oen obliterated and may be very difcult to delineate and follow. is situation is of particular relevance
with regard to the autonomic nerves and presacral veins, which normally sit behind the endopelvic or presacral fascia. Disturbance of
these fascial planes exposes the nerves and veins to damage. Finally,
disease or treatment-specic factors such as sepsis, recurrent cancer,
irradiation, and obstruction all can add signicant diculty to a surgical approach.
Approach to Reoperative Pelvic Surgery
Presacral Veins
e presacral veins run beneath the thickened parietal pelvic fascia
that covers the sacrum and coccyx, which is oen referred to as the
presacral fascia. ese veins form a plexus over the lower part of the
sacrum and connect with the large basivertebral veins. ere are no
valves in the connecting veins to prevent or minimize back bleeding,
and the connecting veins themselves are fused to the sacral foramina.
ey cannot contract. Presacral venous bleeding is usually low pressure but resists attempts at control by suture or cautery.
Pelvic Nerves
e sympathetic nerves originate from the hypogastric plexus above
the bifurcation of the aorta and coalesce around the inferior mesenteric artery to form the discrete hypogastric nerves. ese nerves
then cross the pelvic brim behind the presacral fascia to pass laterally
434
Strategy
Planning reoperative pelvic surgery demands a realistic analysis of
the benets to be gained and the risks to be run. is analysis is an
important part of any surgery but assumes critical importance for
a procedure in which the risks are unusually high. Patients must
understand the risks and have realistic expectations. e option of
performing no surgery at all must be discussed.
Preoperative Planning
Timing
Appropriate timing of a repeat operation may reduce the diculty
and potential complications attributable to adhesions. Early reoperative pelvic surgery is usually an emergency, and thus all eorts are
directed to dealing with the urgent problem. Even for emergency surgery, there is a window of about 10 to 14 days before postoperative
COMPLICATIONS 435
adhesions reach their most dense and dangerous. Aer this period,
there is a signicant risk of iatrogenic injury to the bowel because the
inammatory nature of the adhesions at this point in their development predisposes to bowel injury. It is preferable to wait at least 3
months before performing a repeat operation. If something must be
done to divert stool to manage sepsis, approaches such as percutaneous abscess drainage, proximal fecal diversion, or parenteral nutrition can buy time. Factors that may make adhesions worse include
sepsis, ischemia, and irradiation. If these factors are present, a repeat
operation should be delayed at least 6 months.
Patient Preparation
e patient’s nutritional state should be optimal, and comorbidities
should be treated. Long operations, underlying malignancy, and big
incisions increase the risk for postoperative atelectasis and pneumonia, as well as deep venous thrombosis. Aggressive deep venous
thrombosis prophylaxis may sometimes require caval lter placement. Mechanical bowel preparation is a matter of preference, and
many surgeons now believe it is not routine or mandatory.
Define the Anatomy
e preoperative strategy may be aided by imaging and endoscopy
if the exact details of the prior operation are unclear or unreliable.
Knowing the length of a rectal stump or whether there may be an
unexpected “stump blowout” or abscess is very helpful. Computed
tomography (CT) scanning and magnetic resonance imaging (MRI)
also may provide a road map of pelvic anatomy when a signicant
interval change has occurred as a result of a treated abscess or anastomotic leak.
In the case of malignant disease, it is essential to exclude unresectable pelvic cancer or distant metastatic disease that would preclude a curative procedure. Whereas clinical features such as nerve
root or sciatic pain suggest unresectability, determining resectability
of malignant pelvic disease on clinical-pathologic grounds alone can
be unreliable. CT and/or MRI can identify features associated with
either a signicantly lower chance of resectability (pelvic side wall
involvement and ureteric obstruction) or features more oen amenable to curative resections (anterior pelvic or isolated anastomotic
recurrence). Positron emission tomographic–CT scanning is also
routinely performed in the case of malignant pelvic recurrence. In
the absence of sepsis it is usually sensitive and specic for recurrences
greater than 1 cm. Identication of liver or lung metastases that are
not amenable to resection also may discourage a highly morbid palliative pelvic operation. Positron emission tomographic-CT scanning
is also useful in distinguishing postoperative changes from locally
recurrent malignant disease in the pelvis.
Anticipate and Prepare for a Difficult Case
Blood should be cross-matched and the availability of clotting agents,
such as platelets, fresh frozen plasma, and cryoprecipitate should be
conrmed in case massive transfusion is required. Many institutions
now have protocols for massive transfusion in which specic additional blood products and clotting factors are given routinely aer a
specic amount of transfused blood.
Having the right operation at the right time of day by the right
surgical team is well worth the investment. One should start early,
have experienced help, and forewarn anesthesiologists and other subspecialists who may be needed, such as urologists or gynecologists.
Anesthesiologists must be given time to place appropriate lines for
rapid volume administration and monitoring.
can be predicted preoperatively by examining factors such as age,
anal tone/squeeze, extent of intestinal resection, prior irradiation,
and prior pelvic sepsis. Proper informed consent should take these
factors into consideration, and when appropriate, a permanent stoma
should be part of the discussion.
Intraoperative Conduct
Patient Positioning
Careful positioning and padding are essential to avoid injury due to
pressure or poor positioning during a long operation. A bean bag or
a foam pad are good choices and help prevent the patient from slipping down the table if a steep Trendelenburg position is applied. Both
arms should be tucked securely at the patient’s side even if the patient
is obese so as not to limit the room required to obtain adequate access.
e legs are placed in carefully positioned and padded Allen or yellow n stirrups. e hips are not overexed, which would interfere
with a self-retaining retractor placed in the most distal aspect of the
wound. Neither are the hips overextended, in the interest of avoiding
stretch injury to nerves in the anterior compartment of the thigh. e
patient is prepared from the xiphoid to the perineum and draped so
that access to the perineum can be obtained without contaminating
the abdominal eld.
Optimizing Visibility and Exposure
A long midline incision is the standard approach, with the distal end
carried down to the pubis and the proximal incision as far cephalad
as needed. Safe entry to the abdomen may need to be above the umbilicus, away from prior dense adhesions or stulas. Enterocutaneous
stulas are le in place until the bowel around them is fully mobilized
to minimize contamination and avoid injury to uninvolved bowel.
A self-retaining retractor is used, although a variety of retraction
systems are available. A bladder blade can be attached to the selfretaining retractor and is tightened up against the pubic bone. A large
chromic suture can be placed in the dome of the uterus and then tied
around the bladder blade to pull the uterus up out of the pelvis. Once
the small bowel has been brought up out of the pelvis, placing the
patient in the Trendelenburg position will help keep the pelvic eld
clear, or it may be packed away using a “C” arm retractor or a broad
malleable retractor bent into a “U” shape.
Excellent overhead lighting is essential and can be supplemented
by a lightweight ber-optic headlight, as well as lighted retractors.
A number of specialized pelvic retractors are available that are long
and curved to t the shape of the pelvis and can be attached to a
ber-optic light source. e lighted Deaver retractor (Fig. 82-1) has
a relatively shallow curve and is a short, broad instrument that is
ideal for the early part of the posterior rectal dissection. Deeper in
the pelvis we use the deep pelvic retractor, which comes with distal
blade widths from 25 to 50 mm and has two styles of handle, one
named aer the senior author who helped develop it (Fig. 82-2). It is
especially useful in liing the rectum upward and forward with some
Functional Considerations
Although avoidance of a permanent stoma is a laudable goal, the likelihood of good function, continence, and patient satisfaction oen
FIGURE 82-1 A lighted Deaver retractor with handle (ESI/FTT Medi-
cal Inc., Rochester, N.Y.).
ReopeRative pelvic SuRgeRy436
degree of force to accentuate the correct plane of dissection behind
the rectum. In addition, it can be used to retract the bladder and prostate or vagina forward to assist with anterior visualization and dissection. An alternative is the St. Mark retractor, which also comes in a
curved and lighted model (Fig. 82-3).
Access to the Pelvis
Once the abdomen has been entered, the small bowel needs to be delivered up out of the pelvis where it is oen fused to the vagina, rectal
stump, levators, or anterior sacrum. e aerent and eerent loops
descending into the pelvis need to be identied and gently retracted
with the nondominant hand to try to visualize the apex of the loop.
Sharp dissection is performed close to the bowel wall, and enterotomies
or myotomies may be unavoidable or incidental, necessitating repair or
resection once mobilized out of the pelvis and separated. Dissection of
the densest adhesions may be facilitated by inltrating the fused area
with saline solution using a small-gauge needle (hydrodissection). is
maneuver preferentially expands the correct plane for dissection and
reduces the likelihood of bowel injury. It also may be of value in nding a plane between the vagina and the previously mobilized rectum.
If no progress is being made in exposing or dening the pelvic
anatomy, one must decide early if the potential for harm is becoming
greater than the potential for good. If so, temporizing measures such
as drain placement or proximal diversion are options, and further
waiting or referral to surgeons with more experience should be considered. ink carefully before “crossing the Rubicon” by dividing the
blood supply or irreparably damaging bowel, or getting into bleeding
in an area where it cannot be controlled.
Identification of Specific Pelvic Structures
Ureter
Early identication of the ureters on both sides of the pelvis in which
a repeat operation is being performed is the key to avoiding injury.
In a densely scarred pelvis, the ureters are found proximally and
traced to the pelvis. ey may be marked by loosely placed encircling ligatures and are constantly referred to during conduction of
the dissection. Ureteric blood supply is segmental, and thus excessive
mobilization may lead to ischemia.
Preoperative placement of ureteric stents increases cost and time
but allows ureteric damage to be recognized. If a stent is not or cannot be placed, the intravenous administration of indigo carmine
(5 mL) will turn the urine blue and can help detect an occult injury
with leaking urine.
A urine leak presents postoperatively as excessive output of a
pelvic drain. e uid has a very high creatinine level. If there is no
drain, presentation may be more subtle with a slight rise in serum
creatinine, an ileus, and ultimately drainage of urine through the
wound. Some ureteric injuries present late with a stricture and varying degrees of hydronephrosis and impaired renal function. e most
common sites of injury are at the pelvic brim and distally.
FIGURE 82-2 A lighted deep pelvic retractor (ESI/FTT Medical Inc.,
Rochester, N.Y.); the “Fazio” handle is on the left, and the standard
handle is on the right.
FIGURE 82-3 A lighted St. Mark retractor with lip and angled blade
(ESI/FTT Medical Inc., Rochester, N.Y.).
Bladder
If the previous abdominal incision was taken down to the pubis for
maximal exposure, the bladder may be densely adherent to the midline fascia in the lower part of the wound where it may be inadvertently injured. e combination of proctectomy and pelvic radiation
causes a tight, restrictive, crescent-shaped band in the deep pelvis
corresponding to a brous bladder base, which will limit exposure
and access to the low pelvic and pelvic oor. is can be managed
by making several supercial cautery incisions in the brous arc and
then stretching the narrow entrance.
Rectal Stump
If prior pelvic dissection and rectal mobilization has been minimal,
the rectal stump usually is not dicult to nd. However, if the rectum was initially divided at or below the sacral promontory, the
stump may retract and the divided end may be adherent to the
presacral fascia, the great vessels, or the ureters. It is sometimes
possible to begin the rectal dissection more distally and laterally
in “virgin tissue” and to start the development of the plane behind
the mesorectum here. Once the peritoneum has been incised, this
is facilitated by retracting the rectum medially using the lighted
Deaver retractor and then using electrocautery to follow the mesorectum posteriorly to the presacral space. e proximal part of the
rectal stump is then mobilized by sharp division of the adhesions,
obscuring the plane between the posterior mesorectum and the presacral fascia. Potentially fused ureters, sympathetic trunks, or vessels are dissected and freed.
Placement of a large bougie or proctoscope in the rectum can
identify a short, nearly invisible rectal stump. Bimanual palpation,
with a hand in the pelvis and a nger transanally, is a useful technique
not only to identify the rectum but also to accurately assess the level
of the dissection in relation to the sphincters. Before any anastomosis is attempted to a defunctionalized rectum, an occult stricture or
inspissated mucus must be excluded, which can be determined either
preoperatively or intraoperatively.
COMPLICATIONS 437
Vagina
In repeat operations, the vagina should always be prepared with
povidone-iodine in case it is inadvertently entered. An obturator or
a bougie may be extremely helpful in the identication and prevention of a vaginal injury. Occasionally, bimanual palpation with one
nger in the rectum and one in the vagina facilitates the separation
of the most distal aspects of the rectum and vagina. If the vagina
is injured, a layered repair is appropriate. Adequate mobilization
from the rectum and care when both passing and closing a stapling
device are keys to avoiding incorporation of the vagina in the anterior part of stapler. Aer prior proctectomy without reanastomosis, the vagina may adhere to the sacrum. It must be mobilized if
reconstruction with a pouch is to be achieved. is procedure is
dicult because bleeding from the presacral plexus may occur if
the dissection is too deep, and entry into the vagina may occur if it
is too shallow.
Autonomic Nerves
Loss of fascial planes aer prior surgery places the sympathetic hypogastric nerves at risk at the pelvic brim. Damage to the nerves can
cause retrograde ejaculation in the male and vaginal dryness in the
female. Both sympathetic and parasympathetic (nervi erigentes)
nerves are at risk anterior to the rectum if Denonvilliers fascia is
inadvertently or necessarily breached. Damage here can cause male
impotence and diculty with urination.
Control of Bleeding
e common sites at which pelvic bleeding is encountered are listed
in Box 82-1.
If the point of signicant bleeding cannot be identied quickly, an
index nger should be used to apply pressure. Should this pressure
fail to stop the bleeding, one should place packs and wait a minute or
so. Good lighting, adequate suction, and good exposure are then the
keys to identifying and addressing the source of the bleeding. Inform
the anesthesiologist of the problem, and allow him or her to catch up
with blood loss and send for more blood. en gently tease out the
packs until the bleeding site is seen. A sponge or small cotton pledget
on an instrument should be used to control the bleeding, thus allowing room to perform measures to stop the bleeding.
Presacral bleeding may be cauterized using a high coagulation
current, but sometimes this maneuver damages adjacent presacral
veins and worsens the bleeding. Suturing with a ¾-circle needle (e.g.,
2-0 Vicryl or Prolene on a UR6 needle) is reasonable if the bleeding
is localized and sucient intact fascia exists on either side to provide
tamponade. If intact fascia is insucient, a sterile thumbtack can be
driven into the sacral foramen with or without some Surgicel secured
beneath it. e thumbtack is best driven home using the at part of
a heavy pair of scissors or a specically designed applier. Should the
area be too large for a single tack, a roll of Surgicel or a 1-cm cube
of rectus muscle may be sewn over the bleeding point again using
a stout ¾-circle needle. If this maneuver does not work, then apply
Surgicel to the bleeding area, pack it, and halt the operation. Aer
48 hours, remove the packs and complete the procedure. Recurrent
bleeding aer 48 hours is rare.
BOX 82-1: Common Sites/Causes of Pelvic Bleeding
• Presacralandlateralsacralveins,whenthepresacralfasciais
inadvertently or deliberately incised
• Internaliliacvein
• Rectovaginal,retroprostatic,andparavesicalveinswithante-
rior/anterolateral dissection
• Sacralorpresacralartery
• Anyofthearterialstructuresinthepelvis
e most important consideration is performing packing early
before the patient experiences massive blood loss and the vicious
downward spiral of coagulopathy and hypothermia has begun. Packs
should be rmly placed at the site of bleeding and not roughly stued
into the pelvis so as to cause shearing of small veins and compounding of the problem. If a pelvic anastomosis was to be created and the
packs need to be retained for 24 to 48 hours, the anastomosis should
be delayed until the packs are removed, because a tightly packed pelvis may compromise the blood supply of the proximal bowel and put
tension on the newly created anastomosis.
Direct injuries to a major vein usually can be managed with repair,
oversewing, or ligation above and below the injury. Arterial injuries
also may be treated by ligation or oversewing if bleeding is from small
distal branches. A single internal iliac artery usually can be ligated
without untoward eects. Injury to the external iliac artery must be
repaired. ese injuries warrant a vascular surgeon’s assistance.
Drainage
We routinely place a drain in the pelvis that has undergone a repeat
operation. If bleeding has been completely controlled, a single
Jackson-Pratt or Blake suction drain will suce. However, if oozing
persists or if fecal contamination has occurred, then sump drains are
used and brought out through a separate stab incision rather than
through the wound. ese drains can be irrigated with normal saline
solution for 48 hours and removed a day or two aer that. e omentum is routinely mobilized as a pedicle gra o the le side of the
transverse colon and brought down the le paracolic gutter to ll
dead space in the pelvis or to wrap around and isolate an anastomosis. Keeping the small bowel out of the pelvis may help prevent future
obstructions. One or two sutures are used to hold the omentum in
the pelvis or to incorporate it into the perineal wound closure in the
case of abdominoperineal resection. Perineal drains are rarely used.
SPECIFIC CLINICAL SITUATIONS
Reversal of Hartmann Procedure for Diverticulitis
Measures to identify and safely mobilize a dicult rectal stump have
been described earlier. Other problems include a midrectal stricture or general rectal atrophy with narrowing, which can make safe
passage of a circular stapler impossible. Sometimes the serial passage of dilators per rectum remedies this problem, but rectal atrophy demands a hand-sewn colorectal anastomosis. A rectal stricture
requires resection to a healthy rectum. It may be tempting to pass the
cartridge of the stapler without the anvil per rectum and to drive the
trocar through either the stapled end of the rectum or the anterior
wall below the staple line. However, if the divided end of rectum is
brotic and thickened, too much is being asked of the stapling device,
and tearing of the anastomosis will occur upon withdrawal. If the
trocar is brought through the anterior rectum too close to the end,
ischemia may develop between the anastomosis and the divided end
of the rectum, with a risk of subsequent perforation.
A hand-sewn anastomosis is a safe technique. Another approach
is a side of colon to end of rectum anastomosis, in which the stapler is passed through the opened end of the distal colon and opened
through the antimesenteric wall, and then connected to the anvil that
has been secured in the rectum with a purse string.
Recurrent Rectal Cancer
Surgery for recurrent rectal cancer must have clear and realistic aims.
If it is palliative, there must be a reasonable chance of improving quality of life. Preoperative staging shows the pattern of recurrence in the
pelvis and predicts the likelihood of success. Features suggesting that
ReopeRative pelvic SuRgeRy438
the recurrence is neither resectable nor curable include preoperative
sciatic pain, lower limb lymphedema, bilateral ureteric obstruction,
retroperitoneal paraaortic lymph node involvement by cancer, and
especially xation of the pelvic mass to the side walls of the pelvis.
Invasion of the sacrum suggests the need for a sacrectomy, and invasion of the prostate or bladder suggests the need for an exenteration.
Here, the probability of cure and/or the quality of palliation must be
balanced against the morbidity and mortality of the surgery.
With the advent of new biologic and chemotherapeutic agents,
survival with stage IV colon and rectal cancer is prolonged, increasing the role of palliative surgery. Preoperative chemotherapy and
radiation (if not already given) should be considered for bulky or
advanced disease. Surgery is performed 8 to 10 weeks later.
Performing a repeat operation for recurrent rectal cancer is difcult. Pelvic brosis and scarring obliterate planes and hide landmarks, and ureteric stents may be impossible to pass, or impalpable
if they are there. Dierentiating postoperative scarring and radiation
eect from recurrent cancer may be dicult; sometimes a frozen
section will be needed. Trial dissection of the presacral space may
come to a halt when real or apparent fusion of a mid–sacral-level
colorectal anastomosis—the site of recurrence xed to the sacrum—
is encountered. In such cases, if a sense of partial fusion is obtained,
the surgeon may choose to dissect posterior to Waldeyer fascia,
which is a bold step, because shearing of the basivertebral veins from
the sacrum may occur. However, the surgeon may be rewarded by
nding a plane in which a brous layer of thickened membrane—or
periosteum—is anterior to the sacrum. Bleeding may be dealt with by
one of the methods described earlier. Although an anastomosis occasionally may be possible, usually distal transection and stapling of the
lower rectum or abdominoperineal resection is required.
Situations previously regarded as absolute contraindications to
resection, such as iliac vessel and ureteric involvement, have been
challenged, with acceptable morbidity and long-term survival in specialized referral centers. Likewise, extended sacropelvic resection,
including even an occasional hemipelvectomy, can be performed at
such centers to obtain high rates of clear margin and acceptable longterm disease-free survival. With these increasingly aggressive resections, oen in irradiated elds, myocutaneous ap reconstruction,
especially using the rectus muscle, can help decrease major perineal
wound complications.
Intraoperative radiation therapy may improve local control of
completely resected recurrent cancer by treating microscopic or
macroscopically positive margins. e development of self-shielded
portable machines (Mobetron, IntraOp Medical Corporation, Sunnyvale, Calif.) means that use may become more widespread.
Redo Ileoanal Pelvic Pouch Procedure
e redo pelvic pouch procedure epitomizes the diculties encountered in benign reoperative pelvic surgery. Not only has extensive
pelvic dissection occurred with removal of the entire rectum, but
a neorectum also has been placed into the pelvis, the blood supply
of which is dependent on a single posterior blood vessel—the superior mesenteric artery. e successful performance of this procedure
emphasizes the principles previously discussed.
e results of a series of redo pelvic pouches at the Cleveland
Clinic highlight some of the problems that can be encountered with
such surgery, yet at the same time illustrate the success that can be
achieved with experience and a well-organized approach to repeat
operations in the pelvis.
From 1983–2007, 241 abdominal reconstructions of pelvic pouches
were performed, with the most common indications being stula, leak,
stricture, and pouch dysfunction. Ureteric stent placement was routine,
and pouches were usually mobilized to the pelvic oor. Although the
posterior pelvic mobilization was oen dicult and inadvertent pouch
enterotomy was common, this was easily repaired.
In 71 cases a new pouch was constructed, and in 171 cases the
original pouch was salvaged. Failure was observed in 29 cases with
either pouch excision or proximal fecal diversion. Long-term pouch
salvage was 85%, and compared with a matched nonrevised pouch
group, only daytime leakage, nighttime leakage, and pad usage were
signicantly higher. All other parameters and quality of life were
similar between groups.
SUMMARY
Reoperative pelvic surgery is oen complex and challenging, with the
need for concomitant urologic, vascular, orthopedic, gynecologic,
and reconstructive assistance. e keys to success are:
1. Careful preoperative planning, patient preparation, and in-
formed consent;
2. An ability to determine when the potential risks outweigh the
benets;
3. Knowing the limits of one’s expertise and the expertise of other
subspecialists who may be needed;
4. A methodical and careful operative approach with good help
and equipment;
5. Knowing when to turn back from the point of no return; and
6. An acceptance that extended resections and complex recon-
structions are probably best performed in a few highly specialized centers with proven expertise and good outcomes.
S u g g e S t e d R e a d i n g
Austin KK, Solomon M. Pelvic exenteration with en bloc iliac vessel resection
for lateral pelvic wall involvement. Dis Colon Rectum. 2009;52(7):1223–
1233.
Colibaseanu DT, Dozois EJ, Mathis KL, etal. Extended sacropelvic resection
for locally recurrent rectal cancer: can it be done safely and with good
oncologic outcomes? Dis Colon Rectum. 2014;57(1):47–55.
Heriot AG, Byrne CM, Lee P, etal. Extended radical resection: the choice
for locally recurrent rectal cancer. Dis Colon Rectum. 2008;51(3):284–291.
Potter KC, Husband JE, Houghton SL, etal. Diagnostic accuracy of serial CT/
magnetic resonance imaging review vs. positron emission tomography/
CT in colorectal cancer patients with suspected and known recurrence.
Dis Colon Rectum. 2009;52(2):253–259.
Mirnezami AH, Sagar PM, Kavanagh D, etal. Clinical algorithms for the sur-
gical management of locally recurrent rectal cancer. Dis Colon Rectum.
2010;53(9):1248–1257.
Remzi FH, Fazio VW, Kirat HT, etal. Repeat pouch surgery by the abdomi-
nal approach safely salvages failed ileal pelvic pouch. Dis Colon Rectum.
2009;52(2):198–204.
N S
C S
John L. Rombeau, Kimberly J. Hwa, and Dan Eisenberg
INTRODUCTION
Surgeons are justiably proud of their seminal contributions to nutritional care of the hospitalized patient. ese contributions include
quantifying the prevalence of malnutrition, conrming the association of malnutrition with adverse clinical outcomes, discovering
parenteral nutrition (PN), and demonstrating, in selected groups of
patients, that providing nutritional support (NS) may either prevent
or correct malnutrition-associated morbidity. Despite the lack of
conrmatory data in many surgical populations, surgeons must still
decide when, what, and how to feed their patients while recognizing
that the alternative is starvation.
In this chapter we review the assessment of nutritional status,
indications for NS, dietary components and their delivery, and new
directions in NS, with particular emphasis on colon and rectal surgery (CRS). For purposes of discussion, NS is dened arbitrarily
as the provision of oral supplements, enteral feeding, or parenteral
nutrients. Every attempt has been made to provide evidence-based
recommendations. A complete discussion of this topic is beyond the
scope of this short review. For more extensive information, the reader
is referred to the Web site of the American Society for Parenteral and
Enteral Nutrition (ASPEN) at http://www.nutritioncare.org/.
NUTRITIONAL ASSESSMENT
e decision to provide NS is based, in part, on measurement of criteria predictive of a malnutrition-induced adverse outcome. It should
be emphasized that these measures are not totally determined by
the patient’s nutritional status; they are also inuenced by the primary diagnosis, degree of metabolic stress, and presence of infection. Extensive information is available on nutritional assessment
for perioperative NS, ranging from sophisticated multivariate indices (which are more feasible with dedicated teams performing these
functions) to more readily performed clinical history and measurement of serum proteins. Important assessment criteria to initiate NS
are shown in Box 83-1.
It should be noted that these criteria are guidelines and not absolute recommendations for NS. Clinical judgment remains the most
important determinant in deciding when, what, and how to feed
patients.
loss and reduced serum proteins. Signicant loss of body weight is
perhaps the most important single indication for NS. Nonvolitional
loss of more than 10% of usual weight within 3 months prior to surgery and/or a serum albumin level less than 3 g/dL in the euvolemic
state are important criteria to initiate some type of perioperative NS
(Box 83-1).
Severe Malnutrition
e indications for NS, particularly for parenteral feeding, have
become more limited during the past 40 years because of the lack
of conrmatory data in the most common groups of minimally and
moderately malnourished patients.
Severe malnutrition in perioperative patients is associated with
adverse postoperative outcomes, including increased infection, poor
wound healing, anastomotic breakdown, coagulopathy, and heart failure. Delaying an elective colorectal operation to improve the patient’s
nutritional status may therefore be benecial, but only if the patient
is severely malnourished. e decision to use NS preoperatively must
be made with an appreciation of the rising costs of health care, issues
with third-party payor reimbursement, and administrative pressures
to decrease hospital stay. In a recent Cochrane Review of preoperative nutrition in patients undergoing digestive tract surgery, it was
concluded that immune-enhancing nutrition and PN had signicant
outcome benets; however, trials evaluating standard enteral or oral
supplemental nutrition were inconclusive.
One of the goals of preoperative nutrition in this patient population is to minimize loss of nitrogen from skeletal muscle by decreasing the duration of fasting and supporting muscle mass and immune
function. Despite these metabolic goals, data only support aggressive NS for the most severely malnourished surgical patients because
neither preoperative PN nor enteral nutrition (EN) provides a clear
benet in either the borderline or mildly malnourished patient.
Moreover, multiple studies that failed to show a clear benet, and
that occasionally showed a detriment in these patients, led ASPEN
to conclude that perioperative NS in patients with cancer should
be limited to persons with severe malnutrition who are likely to be
unable to eat for more than 7 to 10 days aer surgery, as shown in
Box 83-1. PN should be given to patients who will not be able to meet
their nutritional requirements by oral or enteral tube feeds within the
same period.
INDICATIONS FOR NUTRITIONAL SUPPORT
General Indications
General indications for perioperative NS for the patient undergoing
CRS include severe malnutrition as determined clinically by weight
Postoperative Nutrition
With the exception of the severely malnourished preoperative patient,
most NS is provided postoperatively. e traditional postoperative
management of keeping patients “nil by mouth” (NPO) until clinical
signs of return of bowel function are present is no longer justied. To
our knowledge, there is no signicant outcome benet with starting a
clear liquid diet versus a regular or low-residue diet. However, initiating a regular diet oers numerous nutritional advantages, including
439
NutritioNal Support iN ColoreCtal Surgery440
BOX 83-1: Strong and Moderate Indications for
Perioperative Nutritional Support
Strong Indications
ONE of the following:
• Nonvolitionallossof≥10% usual body weight within 2-3 mo
prior to hospitalization
• Serumalbumin<3.0g/dLineuvolemicstate
Moderate Indications
TWO of the following:
• Currentoralintakemeeting<50%oftotalenergyneeds
• Starvation>7days
• Anticipationofnutritionalsupport>7days
• Serumprealbumin<150mg/dLineuvolemicstate
increased caloric intake, decreased protein catabolism and weight
loss, improved patient satisfaction, and decreased length of hospital
stay. Moreover, level 1 evidence supports early postoperative feeding
in patients undergoing elective colon and rectal surgery. Initiation
of enteral feeds within 2 days of surgery shortens postoperative ileus
and enhances return to oral intake. us, it behooves the colorectal
surgeon to anticipate these issues and plan appropriately; for example,
intraoperative placement of feeding tubes may be warranted to allow
for early EN in the malnourished patient with colorectal cancer. PN
should be reserved for patients who cannot meet their nutrient needs
by 7 days aer surgery. Fast-track or enhanced recovery programs
begin oral intake within 24 hours of surgery (see the Early Postopera-
tive Feeding: “Fast Track” section). Early administration of an oral
diet diminishes the duration of a postoperative ileus, decreases postoperative complication rates, and lowers mortality. No signicant
increase in anastomotic leaks or dehiscence occurs, and early feeding
results in a trend toward lower infection rates and decreased length of
hospital stays. e major complication related to the early initiation
of a diet is an increased risk of vomiting and bloating.
Specific CRS Indications
Inflammatory Bowel Disease
Almost all patients with Crohn disease and approximately one third of
those with ulcerative colitis will require surgery. Some degree of malnutrition is common among most perioperative patients with inammatory bowel disease (IBD) because of insucient dietary intake,
malabsorption, chronic inammation, and adverse eects of medications. e extent of malnutrition depends on the chronicity of the disease, its severity, and the degree of involvement of the small intestine.
Preoperative malnutrition, as dened by unintended weight loss,
or decreased serum proteins such as albumin and prealbumin, is
associated with increased postoperative morbidity in persons with
IBD. In fact, a preoperative serum albumin level less than 3.5 g/dL
was associated with an increased risk of anastomotic leak aer colon
resection. us aggressive preoperative and postoperative NS has
been recommended for selected surgical patients with IBD.
Insucient data exist to support either a specic perioperative
feeding regimen or generalized goals of nutritional care for patients
with IBD.
Some patients with Crohn disease have undergone multiple resections of both the small and large intestine, leading to short bowel
syndrome. Nutritional management of these patients is particularly
challenging. is topic is described elsewhere in this book (Chapter 72).
Colorectal Cancer
As in the cohort with IBD, preoperative malnutrition is present in
some patients with colorectal cancer. Cancer stage, type, location
and size, and prior neoadjuvant treatment with chemotherapy and/
or radiation all contribute to decreased nutrient intake. In addition,
the presence of a wasting syndrome, or cancer cachexia, may lead
to severe malnutrition of the patient with colorectal cancer. Malnutrition and severe weight loss negatively aect surgical outcomes
of patients with cancer. In this context, evidence suggests that early
feeding aer surgery is not only safe but is associated with decreased
postoperative morbidity and mortality.
Conrmatory data are lacking to support the use of specic
dietary formulas or the precise timing for initiating NS. In a study
of 963 patients undergoing surgery for colorectal cancer, Gustasson
and colleagues found that closer adherence to an enhanced recovery
protocol resulted in fewer than 25% postoperative complications and
a shorter length of hospital stay when compared with a nonprotocol
group. eir protocol included a high-calorie liquid intake up to 2
hours before surgery (sometimes prohibited by anesthesiologists in
the United States; see the New Directions section) and oral feeding as
early as 4 hours aer surgery.
ESTIMATION OF NUTRIENT REQUIREMENTS
Perioperative nutrient needs have been measured in major clinical
settings ranging from elective surgery to the severely stressed, critically ill patient. Knowledge of caloric and protein requirements is
particularly relevant to the patient undergoing CRS. Consultation
with a clinical dietician is frequently helpful to determine nutrient
requirements, particularly in settings in which the surgeon is less
experienced with these calculations.
Calories
Glucose is the preferred energy source, particularly for NS. When
provided in sucient amounts, glucose reduces protein breakdown
and nitrogen losses by suppressing hepatic gluconeogenesis and limiting the need for amino acids to be oxidized for energy.
Lipid is another important exogenous source of energy. It also
spares nitrogen and is oen given as a supplement to PN-based
carbohydrate in conditions of dicult regulation of serum glucose
levels. With the recognition that nutrition is a requisite component
of complete perioperative care, most patients initially should be prescribed 25 kcal/kg of actual body weight to be increased gradually to
30 to 35 kcal/kg if weight gain is desired.
Protein
Protein is a mandatory component of NS. It is composed of approximately one-sixth nitrogen. Grams of protein can be converted to
grams of nitrogen by dividing by 6.25. is is oen confusing to
surgeons, inasmuch as protein loss is usually expressed as grams
of nitrogen and protein intake is generally calculated as grams of
protein per kilogram of body weight. Based on extensive metabolic
studies in surgical patients, we prescribe approximately 1.5 g of
protein/kg actual body weight/day. Nitrogen losses are monitored
every few days through nitrogen balance by measuring 24-hour
urinary urea nitrogen with an addition of 4 g as an estimate of
fecal and integumentary losses. Positive nitrogen balance correlates with an anabolic state, whereas a negative balance suggests
catabolism.
Estimates of total caloric and protein needs are also based, in part,
on the patient’s body mass index (body weight kg/height cm), listed
in Table 83-1. e caloric ratio of protein:fat:glucose should approxi-
mate 20%:30%:50%. Lipids are delivered separately with PN and are
limited to 20% to 30% of the nonprotein calories as a result of their
tendency for oxidation and free radical formation.