Background Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non‐steroidal anti‐inflammatory drugs (NSAIDs) for reducing ileus after surgery. Methods A prospective multicentre cohort study was delivered by an international, student‐ and trainee‐led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre‐specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury. Results A total of 4164 patients were included, with a median age of 68 (i.q.r. 57–75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1–3, of whom 1061 (92·0 per cent) received non‐selective cyclo‐oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001). Conclusion NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.
Case reportA 26 year old woman presented for preconception counselling. Eight years previously, she had received a live related kidney transplant for end-stage renal failure due to reflux nephropathy. Five years later, bilateral native nephrectomies were performed because of severe hypertension, with angiography excluding significant stenosis of the renal transplant artery. Inactive problems were previous disseminated tuberculosis and herpes zoster. Her medications included azathioprine, prednisolone, felodipine, atenolol, hydralazine, ranitidine, sodium bicarbonate and iron. Serum creatinine had ranged between 0.14 and 0.18 mmol/L during the preceding two years, 24-hour urine protein was 0.72 g/day, haemoglobin was 97 g/dL and serum urate was 0.34 mmol/L.There was evidence of mild residual tertiary hyperparathyroidism with ionised calcium 1.4 mmol/L (normal 1.2-1.3 mmol/L), corrected calcium 2.74 mmol/L (2.15 -2.6 mmol/L) and serum parathyroid hormone 14 pmol/L (1 -7 pmol/L). Bone mineral density a year earlier was normal. She was commenced on iron and folate supplements, and methyldopa and labetalol were substituted for atenolol, hydralazine and felodipine with good control of blood pressure on home and office monitoring.No information on outcomes of pregnancy complicated by tertiary hyperparathyroidism could be obtained from a literature search, nor on personal communications with leading authorities in the areas of transplantation, renal disease and pregnancy. Six months later she conceived. At 13 weeks, serum testing estimated a risk of trisomy 21 of 1:16. This was assumed to be a false result related to her renal dysfunction. A nuchal translucency scan estimated the risk at 1:7000. By 17 weeks of gestation, haemoglobin had fallen to 82 g/dL with serum ferritin 222 Ag/L. Darbopoetin 30 Ag a week was commenced with the haemoglobin rising to 118 g/dL over the next eight weeks. At 30 weeks of gestation, her blood pressure rose without other evidence of superimposed pre-eclampsia. Darbopoetin was ceased and nifedipine was added because of intolerance of higher doses of methyldopa. At 32 weeks of gestation, she was admitted to the hospital because of progressive hypertension. Serum creatinine had risen from 0.14 to 0.16 mmol/L in the preceding week (normal for pregnancy 0.04 -0.07 mmol/L), serum urate was 0.4 mmol/L, the degree of proteinuria was stable,and there was loss of variability on cardiotocogram. After betamethasone administration, caesarean section was performed with delivery of a male infant with birthweight 1568 g. The mothers' blood pressure and renal function improved after delivery with excellent blood pressure control on irbesartan alone and serum creatinine of 0.12 mmol/L at the time of discharge six days postpartum. She elected not to breastfeed because of uncertainty regarding the safety of azathioprine. During the course of pregnancy and the postpartum period, her degree of hypercalcemia was stable (Fig. 1). The paediatric team was notified of the risk of neonatal hypocalcemia and tetany prio...
Background Postoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies. Methods The Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surgery (2011–2015). Multivariable logistic regression was used to predict risk of AKI, with multiple imputation used to account for data missing at random. Prognostic accuracy was assessed for patients at high risk (greater than 20 per cent) of postoperative AKI. Results In the validation cohorts, 12.9 per cent of patients (661 of 5106) in IMAGINE and 14.7 per cent (106 of 719 patients) in Tayside developed 7-day postoperative AKI. Using the OAKS model, 558 patients (9.6 per cent) were classified as high risk. Less than 10 per cent of patients classified as low-risk developed AKI in either cohort (negative predictive value greater than 0.9). Upon external validation, the OAKS model retained an area under the receiver operating characteristic (AUC) curve of range 0.655–0.681 (Tayside 95 per cent c.i. 0.596 to 0.714; IMAGINE 95 per cent c.i. 0.659 to 0.703), sensitivity values range 0.323–0.352 (IMAGINE 95 per cent c.i. 0.281 to 0.368; Tayside 95 per cent c.i. 0.253 to 0.461), and specificity range 0.881–0.890 (Tayside 95 per cent c.i. 0.853 to 0.905; IMAGINE 95 per cent c.i. 0.881 to 0.899). Conclusion The OAKS prognostic model can identify patients who are not at high risk of postoperative AKI after gastrointestinal surgery with high specificity. Presented to Association of Surgeons in Training (ASiT) International Conference 2018 (Edinburgh, UK), European Society of Coloproctology (ESCP) International Conference 2018 (Nice, France), SARS (Society of Academic and Research Surgery) 2020 (Virtual, UK).
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