web viewword count: 1922. abstract. aim: ... observed ileus rate per center was plotted versus the...
TRANSCRIPT
Incidence of Prolonged Postoperative Ileus after Colorectal Surgery: a systematic review
and meta-analysis
A.M. Wolthuis1, MD, G. Bislenghi1, MD, S. Fieuws2, PhD, A. de Buck van Overstraeten1,
MD, G. Boeckxstaens3, MD, PhD, A. D’Hoore1, MD, PhD
1Department of Abdominal Surgery, University Hospital Leuven, Belgium
2KU Leuven- University of Leuven & Universiteit Hasselt, Interuniversity Center for
Biostatistics and Statistical Bioinformatics, Leuven, Belgium
3KU Leuven- Translational Research Center for GastroIntestinal Disorders (TARGID),
University Hospital Leuven, Belgium
Corresponding author:
A.M. Wolthuis, MD
University Hospital Gasthuisberg Leuven, Department of Abdominal Surgery
Herestraat 49
3000 Leuven
Belgium
Tel. +32 16 34 42 65
Fax. +32 16 34 48 32
E-mail: [email protected]
There are no conflicts of interest.
Word count: 1922
Abstract
Aim:
Prolonged postoperative ileus (PPOI) after colorectal surgery remains a leading cause for
delayed postoperative recovery and prolonged hospital stay. Its exact incidence is unknown.
The aim of this systematic review is to investigate the incidence of PPOI in relation to the
definition used.
Method:
Medline, Embase, and the Cochrane Database of Systematic Reviews (up to July 2014) were
searched. Two authors independently reviewed citations using predefined inclusion and
exclusion criteria.
Results:
The search strategy yielded 3,233 citations; 54 were eligible, comprising 18,983 patients.
Twenty-six studies were prospective (17 of these being randomized controlled trials (RCTs))
and 28 were retrospective. Meta-analysis revealed an incidence of PPOI of 10.3 per cent (95
per cent confidence interval (CI) 8.4 to 12.5) and 10.2 per cent (CI: 5.6 to 17.8) for non-RCTs
and RCTs, respectively. Significant heterogeneity was observed for both non-RCTs and for
RCTs. Used definition of PPOI, type of surgery and access (laparoscopic, open), and duration
of surgery lead to significant variability of reported PPOI between studies. A lower PPOI
incidence occurs after laparoscopic colonic resection.
Conclusion:
The reported incidence of PPOI after colorectal resection is about 10%, with a large
variability between studies. A uniform definition of PPOI is needed to allow meaningful inter-
study comparisons and to evaluate strategies to prevent PPOI.
What does this study add to the literature?
This is the first systematic review and meta-analysis on incidence of prolonged postoperative
ileus (PPOI) after colorectal surgery. It shows that PPOI incidence depends on the definition
used. Heterogeneity between studies is explained by the differences in definition of PPOI. It is
a useful study to allow future inter-study comparisons.
Introduction
Prolonged postoperative ileus (PPOI) after colorectal surgery remains a leading cause of
delayed postoperative recovery, failure of enhanced recovery protocols, and prolonged
hospital stay. It is characterized by the presence of nausea and vomiting, inability to tolerate
oral diet, abdominal distension and delayed passage of flatus and stool. Insertion of a
nasogastric tube (NG tube) may be necessary. PPOI hampers patients’ recovery, increases
postoperative morbidity and therefore leads to longer length of hospital stay[1-4]. There is an
ongoing debate on how to define PPOI and as a consequence on its exact occurrence.
Incidences ranging from 3% to 32% have been reported and a variety of definitions are in
use[5-8]. These definitions either relate to the interval between time of surgery and time of
bowel function recovery or relate to the duration patients have an NG tube to avoid vomiting.
These issues have to be carefully considered when assessing and comparing future studies.
Although previous attempts have been made to define POI, this review aims to reflect on the
need for clarity of the definition of prolonged POI in relation to its incidence after colorectal
surgery. Defining PPOI and assessing its incidence is crucial prior to evaluating strategies to
prevent and treat PPOI or reduce the severity of PPOI. Assuming this, we hypothesized that
incidence of PPOI after colorectal surgery depends on the definition used. The aim of this
systematic review and meta-analysis was to investigate this hypothesis.
Method
Search strategy
A systematic search was performed in the electronic databases of Medline (through PubMed),
EMBASE, and the Cochrane Library up to July 2014. Boolean AND/OR operators were used
to combine keywords and MeSH search terms. The following search criteria were used:
keywords (colorectal OR surgery) AND [(postoperative OR postsurgical) AND (ileus OR
prolonged ileus)] and MeSH terms [(ileus) OR (intestinal pseudo-obstruction) AND
colorectal surgery] mapping to preferred terminology and allowing explosion search.
Reference lists of retrieved articles were hand-searched for additional publications. There was
no language restriction. The systematic review was conducted in compliance with PRISMA
guidelines[9].
Study selection
There were no limits to the type of studies: randomized controlled trials, systematic reviews
and meta-analyses, controlled clinical trials, comparative, prospective, and retrospective
studies were considered. Inclusion criteria included all publications concerning postoperative
ileus as a primary or secondary endpoint following colorectal surgery. Papers relating to PPOI
as one of several outcomes when examining unrelated interventions were also included. Only
studies on prolonged postoperative ileus were included. The main prerequisite for inclusion
was that the definition used for PPOI was clearly mentioned in the study. This definition
could either be based on clinical or radiological findings at a certain point of time
postoperatively, or on therapeutic measures, such as reinsertion of the NG tube. If a preset
definition of PPOI was not reported, the study was excluded. Other exclusion criteria were
studies concerning only bowel ‘motility’ (no link to PPOI), and ileus occurring after surgery
other than colorectal surgery. Conference abstracts and case reports were also excluded. Two
independent reviewers selected the studies to be included in the meta-analysis. Of the initially
identified publications, titles and abstracts were screened to exclude non-related articles. Of
the remaining publications, the full text was read to determine whether they were eligible for
inclusion. Discordance in study inclusion between the two reviewers was resolved through
discussion and consultation with an expert specialist.
Data extraction and quality assessment
Relevant data of the included studies were extracted with a standard fill-out form and entered
into an Excel-database. Recorded variables included definition of PPOI referring to clinical,
radiological, therapeutic criteria used to assess the onset of PPOI, time point in days at which
this definition became applicable, incidence of PPOI, numbers of patients enrolled, type of
surgery, type of access (laparoscopic, open), diagnosis, type of study, year of publication,
gender, age, blood loss, body mass index, and duration of surgery. The quality of included
studies was assessed with the Jadad-scale for randomized controlled trials (RCTs) and with
the Newcastle-Ottawa Score (http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp)
for non-RCTs [10-12]. The Jadad scale is a scale-scoring tool that was developed in 1996 and
it is composed of five total points: two points that are related to randomization, two points that
are related to blinding and one point that is related to dropouts. The Newcastle-Ottawa Score
evaluates patient selection, comparability of study groups and outcome assessment. A
maximum of 9 stars can be obtained.
Statistical analysis
A random-effects meta-analysis using the approach of DerSimonian and Laird was used to
combine the estimates of PPOI incidence from various studies (non-RCTs and RCTs)[13].
The analysis was performed on log-transformed odds. Observed ileus rate per center was
plotted versus the number of patients in funnel plots with 99% prediction limits around
overall ileus incidence to illustrate whether the observed between-study variability exceeded
the pure sampling variability. These limits indicated the range wherein 99% of the observed
ileus incidences were expected, if the studies had been drawn from a population with the same
ileus incidence. The larger the study was, the smaller the range. Prediction limits were
constructed based on the binomial distribution with a continuity correction[14]. Heterogeneity
was quantified by the I² statistic, which is the percentage of total variation in study estimates
that is due to heterogeneity[15] and tested by Cochran’s X²-test. Random-effects meta-
regression was used to evaluate if PPOI incidence depended on study and/or patient
characteristics, or put differently, if the observed heterogeneity could be (partially) explained
by these characteristics[16]. This was done for each characteristic separately. Tukey-Kramer
adjustments for multiple testing were used for pairwise comparisons in the meta-regression.
The number of estimates used in the meta-regression varied, depending on (1) availability of
the information in the original article and (2) whether or not the characteristic could vary
within a study. The percentage variability explained by each characteristic was reported,
based on the decrease of between-estimate variance parameters. Note that in settings where
the reported number of patients with ileus equals zero, a value 0.5 was added to numerator
and denominator to obtain values for the estimate (the log-transformed odds) and its variance.
P-values smaller than 0.05 were considered significant. No corrections for multiple testing
were performed. Therefore, a single p-value should be interpreted carefully. All analyses were
performed using SAS software, version 9.2 of the SAS System for Windows.
Results
The predefined search strategy returned 3,233 non-duplicated references (Fig. 1). Publication
titles and abstracts were screened and 117 publications were retrieved for full-text review.
Subsequently, 63 articles were excluded. In total, 54 publications were included with a total
number of 18,983 patients. Seventeen studies were RCTs[17-33], 4 were case-controlled
studies[34-37], 9 were prospective studies[5, 38-45], and 24 were retrospective studies[46-
69]. The methodological quality of the included studies is shown in Table 1 and 2.
In studies with multiple arms, all reported incidences and study characteristics were included
in the meta-analysis. Five different definitions were used for PPOI. According to these
different definitions, different incidences of PPOI were observed (Table 3). Overall, PPOI
was observed in 10.4% of patients in non-RCTs and in 9.1% in RCTs. Many studies fall
outside the 99% prediction limits, visualizing this presence of between-study variability (Fig.
2 and 3). The random-effects estimate for the incidence of PPOI was 10.3% (95% CI: 8.4%-
12.5%) and 10.2% (95% CI: 5.6%-17.8%) for non-RCTs and RCTs, respectively. Significant
heterogeneity was observed for non-RCTs (I2=93%, Q=499, df=36, P<0.0001) and for RCTs
(I2=96%, Q=395, df=16, P<0.0001), respectively. Criteria for reinsertion of the NG tube were
reported in 4 out of 20 non-RCTs and in 5 out of 13 RCTs (Table 4). Vomiting was the most
important clinical sign to reinsert an NG tube, and some studies also included frequency
(number of episodes) and/or amount (in cc) to determine whether or not reinsertion was
necessary.
Non-RCTs
Access used to perform colorectal resection explains the variability between studies for 21%
(P=0.005). Incidence of PPOI after laparoscopic procedures is lower compared to that after
open procedures or after a combination of laparoscopic and open colorectal resections: 7.4%
versus 12.4% (P=0.065) versus 17.7% (P=0.007), respectively. Type of study, definition of
PPOI, diagnosis, age, gender, BMI, duration of surgery, and blood loss did not significantly
explain variability between reported PPOI estimates.
RCTs
A large part (71%) of heterogeneity in PPOI estimates obtained from RCTs is explained by
the difference in the definition of PPOI used. As a result, analyzing 13 RCTs reporting the
same definition of ‘reinsertion of the NG tube’, evidence for between-study variability
disappears (I2=13%, Q=13.7, df=12, P=0.32). Moreover, type of surgery (rectum, segmental
colectomy, or both) and mean duration of surgery also significantly explained variability
between estimates of PPOI incidence. Incidence of PPOI was 6.6% (95% CI: 3.9-10.9%) for
segmental colectomy, 14.2% (95% CI: 7.2-26%) for procedures involving colon or rectum
resections, and 30.9% (95% CI: 12.7-57.8%) for rectal resections (39% explained
heterogeneity, P=0.008). A lower incidence of PPOI after laparoscopic resections was
observed. Incidence of PPOI was 6.4% (95% CI: 3.5-11.5%) after laparoscopic resection, and
10% (95% CI: 6.2-15.8%) after open colorectal resection. Duration of surgery significantly
affected incidence of PPOI (48% explained heterogeneity, P=0.004). Longer operating time
was associated with a higher PPOI-rate (the odds ratio for a difference of 10 minutes equals
2.19). Diagnosis, age, gender, BMI, and blood loss were not significantly related with PPOI.
Discussion
The principal finding of this meta-analysis is that the overall incidence of PPOI after
colorectal surgery is around 10%. This incidence varies and is evidently related to the
definition used. This is an important finding in assessing and comparing future study
outcomes. Moreover, when therapeutic or prophylactic measures are developed, the
magnitude of this postoperative problem should be known. It is necessary to be aware of the
incidence of postoperative complications in order to appreciate the need and result of new
strategies to prevent or shorten PPOI. Standardized and universally accepted endpoints should
be used for evaluating therapeutic interventions[70].
A predefined time interval of bowel function absence or so-called gut dysmotility
differentiates normal postoperative recovery and PPOI. However, the exact point in time
when normal POI changes to PPOI is still subject of discussion. Therefore, it remains difficult
to exactly define and assess PPOI after colorectal surgery due to the lack of an objective
endpoint. In literature, absence of bowel function on postoperative day 3 to 7 has been
proposed to define the interval between normal and PPOI[71-74]. Absence of bowel function
usually involves one or more of the following criteria: nausea or vomiting, inability to tolerate
oral diet over the last 24h, absence of flatus over the last 24h, abdominal distention, and
radiologic confirmation[73]. In 2006, different types of POI (primary, secondary, recurrent,
prolonged) were defined through consensus, and PPOI was defined as absence of bowel
function after the 3rd postoperative day for laparoscopic surgery and after the 5th postoperative
day for open abdominal surgery, respectively[74]. This review showed the use of 5 different
definitions to define PPOI. In 4 of these, a preset interval between surgery and recovery of
bowel function was used. The high statistical heterogeneity between studies with regard to
PPOI incidence could be the result of non-uniform definitions used to detect PPOI. Indeed,
we found that in a subset of studies where the same definition was used, heterogeneity
disappeared. Therefore, the authors propose ‘reinsertion of the NG tube’ as the most relevant
definition of PPOI after colorectal surgery, because this is a straightforward therapeutic act
postoperatively, and can be recorded in prospective trials. Moreover, in the era of fast-track
surgery, omission of an NG tube after colorectal resection is considered standard of care. It
has been shown that routine postoperative nasogastric placement is unnecessary and has been
associated with a higher risk of pneumonia, fever, and delayed return of gastrointestinal
function[75, 76].
Although the present study shows important insight into the relation between definition of
PPOI and postoperative incidence after colorectal surgery, there also are some weaknesses to
be addressed. The major limitation of this meta-analysis is the limited availability of high-
quality prospective studies: 28 out of 54 studies included were retrospective studies. As such,
the quality of the data, especially on the occurrence of PPOI as a postoperative complication,
cannot be assured.
The above-mentioned data should lead to prospective studies evaluating risk factors for PPOI
and strategies for prevention. This frequent postoperative problem results in considerable
patient suffering, and leads to a significant financial burden for the healthcare system[77].
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Legends to the figures
Figure 1. Prisma flow diagram of the systematic literature review.
Figure 2. Funnel plot of non-RCTs. The horizontal line refers to the crude incidence of PPOI
(10.4%), and the dashed lines refer to the 99% prediction limits.
Figure 3. Funnel plot of RCTs. The horizontal line refers to the crude incidence of PPOI
(9.1%), and the dashed lines refer to the 99% prediction limits.
Table 1. Methodological quality of included non-RCTs according to the Newcastle-Ottawa
Scale.
Author, year Type of study
Number of study arms
Definition of PPOI NOS
Franklin, 1997 Retrospective 2 Absence of bowel function on POD 7 4Joo, 1998 Prospective 2 Reinsertion of NG tube 5Longo, 1998 Retrospective 1 Absence of bowel function on POD 5 5Chen, 2000 Prospective 2 Reinsertion of NG tube 7Senagore, 2003 Case-control 4 Absence of bowel function on POD 5 6Franko, 2006 Prospective 1 Absence of bowel function on POD 3 5Zmora, 2006 Retrospective 2 Reinsertion of NG tube 7Tong, 2007 Retrospective 2 Reinsertion of NG tube 7Zargar-Shoshtari, 2008 Case-control 2 Reinsertion of NG tube 7Asgeirsson, 2009 Retrospective 3 Reinsertion of NG tube 8Hellan, 2009 Retrospective 2 Reinsertion of NG tube 6Mohn, 2009 Prospective 2 Reinsertion of NG tube 7Park, 2009 Retrospective 2 Reinsertion of NG tube 4Shabbir, 2009 Case-control 2 Absence of bowel function on POD 3 5Watanabe, 2009 Retrospective 2 Reinsertion of NG tube 4Zargar-Shoshtari, 2009 Prospective 2 Reinsertion of NG tube 6Zmora, 2009 Retrospective 2 Reinsertion of NG tube 5Delaney, 2010 Prospective 1 Absence of bowel function on POD 5 5Kahokehr, 2010 Prospective 2 Reinsertion of NG tube 6Singh, 2010 Retrospective 1 Reinsertion of NG tube 5Abodeely, 2011 Prospective 2 Reinsertion of NG tube 8Itawi, 2011 Retrospective 2 Absence of bowel function on POD 3 7Kronberg, 2011 Retrospective 1 Absence of bowel function on POD 5
OR Reinsertion of NG tube7
Poon, 2011 Retrospective 2 Absence of bowel function on POD 5 7Raue, 2011 Prospective 2 Reinsertion of NG tube 6Kuruba, 2012 Retrospective 3 Absence of bowel function on POD 5
OR Reinsertion of NG tube8
Millan, 2012 Retrospective 1 Absence of bowel function on POD 5 9Pelloni, 2012 Retrospective 1 Reinsertion of NG tube 6Chapuis, 2013 Retrospective 1 Absence of bowel function on POD 3 9Harbaugh, 2013 Retrospective 3 Absence of bowel function on POD 7 4Kim, 2013 Case-control 2 Reinsertion of NG tube 8
Kolozsvari, 2013 Retrospective 2 Reinsertion of NG tube 7Manceau, 2013 Retrospective 1 Reinsertion of NG tube 4Reshef, 2013 Retrospective 6 Absence of bowel function on POD 5 4Reshef, 2013 Retrospective 2 Absence of bowel function on POD 5 5Vather, 2013 Retrospective 1 Absence of bowel function on POD 3 8Gu, 2014 Retrospective 2 Absence of bowel function on POD 5
OR Reinsertion of NG tube4
NG; Nasogastric, NOS; Newcastle-Ottawa Score, POD; Postoperative day, PPOI; Prolonged postoperative ileus
Table 2. Methodological quality of included RCTs according to the Jadad scale.
Author, year Number of study arms
Definition of PPOI Jadad scale quality assessment
Ortiz, 1996 2 Reinsertion of NG tube 3Ortiz, 1996 2 Reinsertion of NG tube 2Schwenk, 1998 2 Reinsertion of NG tube 1Stewart, 1998 2 Reinsertion of NG tube 3Smith, 2000 2 Reinsertion of NG tube 1Targarona, 2002 2 Reinsertion of NG tube 3Veldkamp, 2005 2 Absence of bowel function on POD 3 3Taqi, 2007 2 Reinsertion of NG tube 1Hewett, 2008 2 Reinsertion of NG tube 3El Nakeeb, 2009 2 Reinsertion of NG tube 1Kang, 2010 2 Reinsertion of NG tube 3Meng, 2010 2 Absence of bowel function on POD 5 2NG, 2010 3 Reinsertion of NG tube 4Vlug, 2011 4 Absence of bowel function on POD 5 3Deng, 2013 2 Reinsertion of NG tube 5Zaghiyan, 2013 2 Reinsertion of NG tube 3Boelens, 2014 2 Absence of bowel function on POD 5
OR Reinsertion of NG tube3
NG; Nasogastric, POD; Postoperative day, POI; Postoperative ileus
Table 3. Incidence of PPOI in relation to definition
Definition Non-RCTs RCTs
Number of studies
Incidence (95%CI)
Number of studies
Incidence (95%CI)
Reinsertion of NG tube 20 9.5 (6.8-13) 13 8.4 (6-11.6)
Absence of bowel function POD 3 5 10.1 (5.4-18) 1 2.3 (0.8-6.8)
Absence of bowel function POD 5 7 11.7 (7.1-18.9) 2 21.7 (11-38.3)
Absence of bowel function POD 7 2 8.1 (2.9-20.6) NA
Absence of bowel function POD 5
OR Reinsertion of NG tube
3 12.6 (5.9-25) 1 61 (33.7-82.7)
NA; Not Available, NG; Nasogastric, POD; Postoperative day, Values are percentages, Values in parentheses are 95% confidence intervals
Table 4. Criteria for NG tube reinsertion from included non-RCTs and RCTs.
Author, year Criteria for NG tube reinsertionNon-RCTsJoo, 1998 Nausea or vomiting of > 200 ccChen, 2000 ≥ 2 episodes of vomiting of > 200 cc without bowel movementZmora, 2006 NRTong, 2007 NRZargar-Shoshtari, 2008 NRAsgeirsson, 2009 NRHellan, 2009 NRMohn, 2009 NRPark, 2009 NRWatanabe, 2009 NRZargar-Shoshtari, 2009 NRZmora, 2009 Abdominal distention or vomiting, based on clinical judgementKahokehr, 2010 NRSingh, 2010 Abdominal distention or vomiting, based on clinical judgementAbodeely, 2011 NRRaue, 2011 NRPelloni, 2012 NRKim, 2013 NRKolozsvari, 2013 NRManceau, 2013 NRRCTsOrtiz, 1996Ortiz, 1996Schwenk, 1998
2 episodes of vomiting2 episodes of vomitingNR
Stewart, 1998 Vomiting of > 100 cc on 2 occasions within 24 hSmith, 2000 Clinical judgementTargarona, 2002 NRTaqi, 2007 NRHewett, 2008 NREl Nakeeb, 2009 2 episodes of vomiting without bowel movementKang, 2010 NRNg, 2010 NRDeng, 2013 NR
Zaghiyan, 2013 NRNG; Nasogastric, NR; Not reported