3

PERIOPERATIVE CARE
69
Informed consent
Patient information
70
70
Risk
Measuring risk
70
Communicating risk: disclosure of
risk
80
81
Risk management
Mechanical bowel
preparation
81

Colorectal surgery and surgical site

infections
89
Thromboembolism prophylaxis
99
Transfusion and bleeding
105
Colorectal patients and highdependency care: evolution
of the surgical high-dependency
unit
105

INFORMED CONSENT
Colorectal surgical practice encompasses invasive surgical interventions that range from outpatient endoscopic
and digital examination to proposing pelvic clearance and
sacrectomy for a recurrent rectal cancer. The purpose of a
colorectal procedure is to restore an individual to health:
a state of complete physical, mental and social well-being,
not merely the absence of disease or infirmity. By the very
nature of the conditions dealt with and the surgical procedures employed, a proportion of patients admitted to a
colorectal service will become ill, develop life-long disability and, in some cases, die from the surgical intervention.
Many patients therefore correctly fear that consenting to
a colorectal procedure could result in mutilation, disruption of body image, destruction of sexuality and an inability to function in society. Perioperative care in colorectal
practice has to address all of these mental, physical and
social concerns when preparing the individual patient and
his or her family for the planned procedure.
The key element in proceeding with an invasive colorectal intervention is to obtain from the patient informed
consent. This is now widely recognised as more than getting a patient to sign a written consent form. The American
Medical Association has defined it as a process of communication between a patient and physician that results in the
patients authorisation or agreement to undergo a specific
medical intervention. The British Medical Association
(BMA) has issued the following principles that not only represent good practice but go beyond the legal minimum for
UK practice:

Patient consent must be voluntary, free from pressure and

arise from a competence to decide.
Patient consent is required on every occasion the doctor
wishes to initiate an examination or treatment or any
other intervention, except in emergencies or where the
law prescribes otherwise. Consent can be verbal, written
or implied by acquiescence by a person who understands
what will be undertaken. Acquiescence when a patient

Anaesthesia for colorectal

surgery
107
Colorectal surgery and
nutrition
115
Enhanced recovery after colorectal
surgery
123
126
References

does not know what the intervention entails or that there

is an option of refusing is not consent.
The amount of information doctors provide to each
patient will vary according to factors such as the nature
of the condition, the complexity of the treatment, the risks
associated with the treatment or procedure, and the
patients own wishes. The General Medical Council
requires doctors to take appropriate steps to find out what
patients want to know and ought to know about their
condition and its treatment.
The doctor who recommends that the patient should
undergo the intervention should have responsibility for
providing an explanation to the patient and obtaining his
or her consent. In a hospital setting this will normally be
the senior clinician. In exceptional circumstances the task
of reaffirming this consent may be delegated to a doctor
who is suitably trained and qualified, is sufficiently familiar with the procedure and possesses the appropriate
communication skills.
Generally, there is no legal requirement to obtain written
consent. The consent form simply documents that some
discussion about the procedure or investigation has taken
place. The quality and clarity of the information given is
the paramount consideration.
Consent forms are evidence of a process; they are not the
process itself. Any discussion, however, should be recorded
in the patients medical notes.
Competent patients are entitled to refuse consent to
treatment even when doing so may result in permanent
physical injury or death.
Legally, in England, Wales and Northern Ireland, no person can give consent to medical treatment on behalf of
another adult. Doctors may treat a patient who lacks
capacity, without consent, providing it is necessary and
in the patients best interests. In Scotland, in some cases
a proxy decision maker may be involved.
Where a minor lacks capacity, a person or local authority with parental responsibility can give consent on behalf
of the patient. Competent minors can give consent to
examination or treatment, but it does not necessarily

70

Chapter 3

Perioperative Care

follow that they have the same right to refuse treatment.

The courts have made clear that, in England, Wales and
Northern Ireland, parents and courts do not lose their
right to give consent on behalf of a competent young person under the age of 18 even if the patient has refused the
treatment. It is possible that the Human Rights Act will
change the outcome of such cases in the future. In
Scotland, it is unlikely that a competent young persons
refusal can be overridden.
The principles of informed consent described by the
American Medical Association are similar (see http://www.
ama-assn.org/ama/pub/category/4608.html) and include
the patient and surgeon discussing the following:

The patients diagnosis, if known.

The nature and purpose of a proposed treatment or procedure.
The risks and benefits of a proposed treatment or procedure.
Alternatives (regardless of their cost or the extent to
which the treatment options are covered by health insurance).
The risks and benefits of the alternative treatment or procedure.
The risks and benefits of not receiving or undergoing a
treatment or procedure.

PATIENT INFORMATION
Procedure-specific information that is relevant, understood
and retained by the patient is a key element in informed
consent. Over a timely period the patient and family should
be allowed to develop an informed view of benefits and hazards of the proposed procedure so that they take ownership of the decision to proceed or not to proceed with the
planned surgery. In practice, the proposed procedure, along
with alternative courses of action and possible complications, requires discussion between the patient and the surgeon. It is useful for the patient to be accompanied by a
friend or family member when these discussions take
place. As well as the surgeon, the specialist colorectal
nurse also provides an important source of information.
Torkington et al (2003) examined the sources of information patients and their families used to make a decision as
to whether or not to undergo an ileoanal pouch procedure.
Preoperatively, 59 of 65 (91%) patients felt that the
colorectal nurse specialist and/or the consultant surgeon
had been the most influential source of information in the
decision to have a pouch procedure.
Videotaped or DVD information enhances significantly
patient knowledge about a procedure when compared to
verbal information alone (Rossi et al, 2004). However,
within colorectal practice, both DVDs and leaflets have
been shown to increase a patients knowledge with respect
to cancer surveillance in ulcerative colitis with mean
percentage improvements in scores of 71% [95% confidence interval (CI) 40.2100] and 49% (95% CI 32.166),
respectively (Eaden et al, 2002). As to the content of
patient information leaflets, a comparison has been made
for patients undergoing gynaecological laparoscopy in
which patients were randomised to receive one of two information leaflets. The old leaflet consisted of information

about the procedure (including a diagram of the pelvic

area), anaesthesia, preparation and normal after-effects,
organised as one section. The new leaflet covered exactly
the same content, with two differences, it omitted the diagram and included two brief paragraphs headed What are
the possible risks or complications? (Garrud et al, 2001).
Whereas knowledge and patient satisfaction was higher
amongst patients receiving the detailed complication information, the anxiety score was the same for both sets of
patients. In clinical practice it is helpful to outline the outcomes and risks of a proposed procedure in correspondence
to both the referring clinician and the patient if they
request this. Such correspondence should include all
options including the option of doing nothing.
The internet is a new and powerful source of patient
information (Table 3.1). Gilliam et al (2003) studied
patients undergoing follow up for Barretts oesophagus or
colonic polyps. Patients received a postal questionnaire
seeking details of internet access and other sources of disease specific information. The majority of patients (88%,
n = 141) wanted more information on their condition.
Interestingly, although 45% (73) had home internet access,
and a further 32% (52) had access to the web from other
sources, only 8% (12) had used the internet as a source of
information; however the majority (57% of patients) said
they would access a recommended website. Al-Bahrani and
Plusa (2004) have investigated the quality of internet sites
available for colorectal cancer patients. In their analysis,
Google identified 55 700 sites for the search term colorectal cancer and 214 000 for bowel cancer. Hotbot
produced 27 700 and 190 000, respectively. Of 400 sites
studied in detail, 118 (30%) provided information, 70
(18%) were lists of links, 27 (7%) were adverts, 22 (6%)
promoted medical centres, 51 (13%) were dead links and
15 (4%) were message boards. Of the 118 that provided
information, 73 (62%) advised on treatment and 73 (62%)
were designed for patients. The sources of information were
clear in 55 (47%) and the date when this information was
reported was given in only 63 (53%). Sites were classified
as excellent 18 (15.3%), very good 19 (16.1%), good 28
(23.7%), fair 8 (6.8%) and poor 45 (38.1%). The authors
(Al-Bahrani and Plusa, 2004) concluded that clinicians
should guide patients as to the quality of internet sites to
avoid confusion and misinformation.

RISK
Risk: an unwanted event that might or might not occur.

MEASURING RISK
Unwanted outcomes in colorectal surgery include postoperative death, formation of a stoma, prolonged postoperative illness, loss of pelvic autonomic function and recurrence
of disease. Of these events, the risk of postoperative death
and illness has been addressed by the development of preoperative scoring systems. Not only are these risk-assessment tools intended to inform individual patients of the risk
they face from a particular procedure, risk-adjusted outcomes are also intended to allow comparison between institutional outcomes and individual surgeon outcomes. Jones

Risk

TABLE 3.1

INTERNET SOURCES OF PATIENT INFORMATION IN COLORECTAL SURGERY

American Society of Colon and Rectal

Surgeons: http://www.fascrs.org
Anal abscess/fistula
Anal cancer
Anal fissure
Anal warts
Bowel incontinence
Colonoscopy
Virtual colonoscopy
Colorectal cancer
Colorectal cancer surgery
Constipation
Crohns disease
Diverticular disease
Haemorrhoids
Irritable bowel syndrome
Ostomy
Pilonidal disease
Polyps of the colon and rectum
Pruritus ani
Rectal prolapse
Rectocele
Ulcerative colitis

Crohns disease
GTN (0.2%) ointment
Haemorrhoids
Lateral anal sphincterotomy
Left hemicolectomy
Polyps
Pruritus ani
Rectal cancer
Right hemicolectomy
Tests for bowel problems
Ulcerative colitis

Association of Coloproctology of Great Britain

and Ireland: http://www.acpgbi.org.uk
ACE procedure
Abdominperineal excision of rectum
Anal abscess/fistula
Anal fissures
Anorectal tests
Anal warts
Anterior resection of the rectum

Stomas
http://www.uoa.org
http://www.the-ia.org.uk

Other useful websites

Colorectal cancer
http://www.patient.co.uk
http://www.cancerresearchuk.org/
http://www.nice.org.uk
http://www.cancer.org
http://www.gastro.org
http://www.ccalliance.org
http://www.hereditarycc.org
http://www.nci.nih.gov
http://www.naric.com

Inflammatory bowel disease

http://www.nacc.org.uk
http://www.mayoclinic.org/crohns
http://www.ileostomypouch.demon.co.uk
http://www.j-pouch.org

ACE, Antegrade continent enema; GTN, glyceryl trinitrate.

and de Cossart (1999) using a Medline literature search

identified a wide range of preoperative and physiological
scores of severity of illness.

ASA grade
The grading system produced by the American Society of
Anesthetists (ASA) (Table 3.2) uses history and examination to give a subjective evaluation of a patients clinical
state before conducting an anaesthetic procedure. If the
procedure is conducted as an emergency, E is added to the
grade to signify a worse prognosis for each category (Jones
and de Cossart, 1999).
In a prospective study of 3250 elective surgical patients,
Klotz et al (1996) confirmed that high ASA grade was asso-

ciated with subsequent postoperative morbidity. Similarly,

in a population of 6301 vascular and general surgery
patients, increasing ASA classification was strongly associated with postoperative death and the risk of postoperative complications (Wolters et al, 1996). When estimating
the increased risk odds ratio for single variables, the risk of
complication was influenced mainly by ASA class IV (risk
odds ratio = 4.2) and ASA class III (risk odds ratio = 2.2).
The subjective nature of the ASA grade and possible
inconsistency in its use has attracted some criticism.
Haynes and Lawler (1995) sent a postal questionnaire to
113 anaesthetists, of varying degrees of experience, working in the Northern Region of England. Each anaesthetist
was asked to give an ASA grade to ten hypothetical

TABLE 3.2
SYSTEM

AMERICAN SOCIETY OF ANESTHETISTS (ASA) GRADING

ASA grade
I
II
III
IV
V

Description
Normal healthy individual
Mild systemic disease that does not limit activity
Severe systemic disease that limits activity but is not incapacitating
Incapacitating systemic disease which is constantly life threatening
Moribund, not expected to survive 24 hours with or without surgery

71

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Chapter 3

Perioperative Care

patients. In no case was there complete agreement on ASA

grade and in only one case were responses restricted to two
of the five possible grades. Despite these concerns, the ASA
grade is a bedside tool that persistently correlates with the
risk of an adverse outcome in patient populations after
surgical intervention.

Surgical risk scale

In this system, each surgical procedure (Sutton et al, 2002)
is allocated a score based on confidential enquiry into postoperative death (CEPOD) scheduling, BUPA (private health
insurance schemethe largest in the UK) operative severity and ASA grade (Table 3.3). The scoring system was developed using 3144 procedures associated with 134 deaths and
validated using 2024 procedures associated with 62 deaths.
Univariate logistic analysis of the surgical risk scale (SRS)
score revealed it to be significantly predictive of death and
showed that it did not over predict death in low-risk procedures. Brooks et al (2005) compared the SRS, Physiological
and Operative Severity Score for the enUmeration of
Mortality and morbidity (POSSUM) and Portsmouth POSSUM (P-POSSUM) scores in 949 consecutive patients undergoing inpatient surgical procedures in a district general
hospital under the care of a single surgeon. The observed
30-day mortality rate was 8.4%. Mean mortality rates predicted using SRS, POSSUM and P-POSSUM scores were
5.9%, 12.6% and 7.3%, respectively. No significant difference was observed in the area under the receiver-operating
characteristic (ROC) curves for the three methods. Specific
risk models can be used to accurately predict mortality, as
for instance one specifically designed for elderly patients with
colorectal cancer, where risk benefit of surgical intervention
is particularly important in deciding whether an operation
is advisable (Heriot et al, 2006).

TABLE 3.3 SURGICAL RISK SCALE

(AFTER SUTTON ET AL, 2002)
Factor
CEPOD
Elective
Scheduled
Urgent
Emergency

Score
1
2
3
4

BUPA
Minor
Intermediate
Major
Major plus
Complex major

1
2
3
4
5

ASA
I
II
III
IV
V

1
2
3
4
5

ASA, American Society of Anesthetists; BUPA, British United

Provident Association (British private health insurance scheme);
CEPOD, confidential enquiry into postoperative death.

Cardiopulmonary risk
The Goldman Cardiac Risk Index was specifically designed
to predict the risk of cardiac complications following noncardiac surgery. Nine factors are scored, giving a total possible score of 053, factors included age, myocardial
infarction in the previous 6 months, S3 gallup or jugular
venous congestion, non-sinus rhythm and more than five
premature ventricular contractions per minute (Jones and
de Cossart, 1999). Prause et al (1997) studied 16 227 surgical patients in whom ASA grade and Goldman Cardiac
Risk Index were determined preoperatively. Both indices correlated significantly with perioperative mortality, the ASA
grade showing a closer correlation. A regression tree analysis divided the combination groups into five subgroups; the
mortality was lowest (0.4%) in ASA grade 2 and Goldman
Cardiac Risk Index group I (score 05 points) and increased
up to 7.3% in ASA grade = 4 and Goldman Cardiac Risk
Index group 3 (score > 13 points). Thus, combining both
scores can increase the perioperative prediction of postoperative mortality (Prause et al, 1997) (Figure 3.1).
Gilbert et al (2000) compared four existing methods
for predicting cardiac risk in 2035 patients: ASA,
Goldman Cardiac Risk Index, modified Detsky Index and
the Canadian Cardiovascular Society Index. Cardiac
complications (myocardial infarction, unstable angina,
acute pulmonary oedema or death) were seen in 6.4% of
the patient population. The area under the ROC curve
was 0.625 (95% CI 0.5750.676) for the ASA grade,
0.642 (95% CI 0.5880.695) for the Goldman Index,
0.601 (95% CI 0.5440.657) for the modified Detsky
index and 0.654 (95% CI 0.6010.708) for the Canadian
Cardiovascular Society Index. These values were not significantly different and Gilbert et al (2000) concluded
that existing indices for prediction of cardiac complications perform better than chance, but that no index is
significantly superior to the others.
The prediction of pulmonary complications after noncardiac surgery is less well explored. McAlister et al (2005)
determined the incidence of postoperative pulmonary complications in 1055 consecutive patients attending the
preadmission clinic of a university hospital (mean age 55
years, 50% men, 15% with history of obstructive airways
disease). Overall, 2.7% suffered a significant pulmonary
complication within 7 days of surgery: 13 patients developed respiratory failure requiring ventilatory support, nine
pneumonia, five atelectasis requiring bronchoscopic intervention, and one pneumothorax requiring intervention.
Multivariate analyses revealed that four preoperative factors were independently associated with increased risk of
pulmonary complications: age [odds ratio (OR) 5.9 for age
65 years, P < 0.001], positive cough test (OR 3.8, P =
0.01), perioperative nasogastric tube (OR 7.7, P < 0.001)
and duration of anaesthesia (OR 3.3 for operations lasting
at least 2.5 hours, P = 0.008).

Colorectal scoring systems

ACPGBI colorectal cancer model
This model (Tekkis et al, 2003b) was constructed with
data from 73 hospitals, forwarded on a voluntary basis
to the Association of Coloproctology of Great Britain and
Ireland (ACPGBI) and encompassing 8077 new cases of

Risk

Figure 3.1 Classification and

regression tree analysis showing
increased predicting power of the
two scores combined. Figures are
per cent mortality. From Prause et al
(1997).

ASA 3

YES

NO

ASA 2

CRI II

YES

NO

YES

NO

4.40%

7.29%

CRI I

0.40%

YES

NO

1.36%

3.19%

colorectal cancer. Factors initially considered included

age, sex, ASA grade, cancer site, procedure, urgency,
Dukes stage, cancer excision and case volume. In 30% of
the 7374 patients used for the analysis, 2216 did not
have recorded ASA grades. The overall postoperative in
hospital mortality was 7.5% and the independent predictors of death were age, ASA grade, Dukes stage, urgency
of the operation and cancer excision (Table 3.4). A score
can be calculated for each factor and converted into an
individual risk.
The authors of the model (Tekkis et al, 2003a) propose
that it can be used to give individual patients and their
carers an estimated probability of survival from surgery.
However, two of the five variables (resection/no resection
and Dukes stage) are available only after patients have
subjected themselves to the irrevocable step of surgical
resection. As such, the model has limited application to
communicating preoperative risk. In addition, the ACPGBI
colorectal cancer (CRC) model might be accurate for elective cases but appears to significantly underestimate predicted mortality in the emergency setting, both actual and
predicted by P-POSSUM. This could be due to a failure to
incorporate adequate weighting for faecal peritonitis and
the associated systemic insult into the ACPGBI model
(Metcalfe et al, 2005)
Cleveland clinic ileal pouch failure model
When counselling patients as to the risks and benefits of
ileal pouch surgery it would be useful to identify those
patients that might be at risk of ileoanal pouch failure
defined as excision of the ileoanal pouch (Fazio et al, 2003).
The Cleveland Clinic model considered risk factors in 1965
patients including the presence of prior anal pathology
(perianal abscesses, fistula-in-ano, fissure-in-ano, or significant haemorrhoids/skin tags), extraintestinal manifestations of inflammatory bowel disease, patient comorbidity
(cardiac, respiratory, renal impairment, diabetes or morbid

obesity), preoperative diagnosis, anal sphincter manometry (mean resting pressure and squeeze pressure measured
in mmHg) and previous abdominal operations, Other factors taken into consideration included details of surgical
procedures, postoperative pathologic diagnoses along with
the early (within 30 days of surgery) and late complications. Pelvic sepsis was defined as the presence of parapouch abscesses and excluded anastomotic leak and
pouch-related fistulae, which were recorded as separate
complications. Chronic pouchitis was defined as four or
more episodes of pouchitis per year or the need for chronic
antibiotic, immunosuppressive therapy to control symptoms, in addition to endoscopic evidence of pouch inflammation (Fazio et al, 2003). The median patient follow-up
was 4.1 years (range 019 years). Five-year ileal pouch survival was 95.6% (95% CI, 94.496.7). The following risk
factors were found to be independent predictors of pouch
survival: patient diagnosis, prior anal pathology, abnormal
anal manometry, patient comorbidity, pouch-perineal or
pouch-vaginal fistulae, pelvic sepsis, anastomotic stricture
and separation.
Although an interesting approach to counselling and
selecting patients for ileoanal pouch surgery, the ileal pouch
failure model has two significant problems (Marcello,
2004). The first is that of all the numerous factors considered in the model, only four can be determined before surgery: prior anal pathology (perianal abscess, fistula-in-ano,
anal fissure, haemorrhoids), preoperative diagnosis (Crohns
disease versus ulcerative colitis and indeterminate colitis),
patient comorbidity (cardiac, respiratory, renal, diabetes,
morbid obesity) and a weak anal sphincter by manometry.
The other risk factors that arise from pouch surgery and
associated complications are not known when the patient
is trying to get a view of the likelihood of success or failure,
i.e. before committing to the procedure. The second problem
is how applicable is the model to other colorectal centres
offering pouch surgery (Marcello, 2004).

73

74

Chapter 3

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TABLE 3.4 THE COLORECTAL CANCER MODEL OF THE ASSOCIATION

OF COLOPROCTOLOGY OF GREAT BRITAIN AND IRELAND (ACPGBI)
AND CONVERSION CHART OF ACPGBI SCORE TO PREDICTED 30-DAY
OPERATIVE MORTALITY FOR PATIENTS UNDERGOING SURGERY FOR
COLORECTAL CANCER
Risk factor

Score

ACPGBI colorectal
cancer score

Predicted
mortality (%)

Age (years)
< 65
6574
7584
8495
> 95

0
0.7
1.1
1.3
2.6

0
0.10.4
0.50.8
0.91.2
1.31.6

0.8
0.91.1
1.31.7
1.92.5
2.83.7

Cancer resected
ASA I
ASA II
ASA III
ASA IVV

0
0.8
1.6
2.5

1.72.0
2.12.4
2.52.8
2.93.2

4.15.4
6.07.9
8.611.3
12.316.0

Cancer not resected

ASA I
ASA II
ASA III
ASA IVV

1.7
1.8
2.1
2.4

3.33.6
3.74.0
4.14.4
4.54.8

17.422.1
23.929.8
31.938.7
41.148.5

Cancer staging
Dukes A
Dukes B
Dukes C
Dukes D or any metastases

0
0
0.2
0.6

4.95.2
5.35.6
5.76.0
6.16.4

51.058.4
60.867.7
69.975.8
77.682.4

Operative urgency
Elective
Urgent
Emergency

0
0.8
1.1

6.56.8

83.887.4

After Tekkis et al (2003b).

Physiological scoring of illness severity

POSSUM development
The Physiological and Operative Severity Score for the
enUmeration of Mortality and morbidity was developed by
Graham Copeland (Copeland et al, 1991) to provide riskadjusted mortality rates in general surgery. From a starting point of measuring 62 factors, the authors were able
to use multivariate analysis to identify the most important
predictors: 12 physiological and 6 operative factors (Table
3.5). Thus, although other factors might be significant in
surgical outcome, their contribution did not add to the
power of the selected 18 factors. To approximate to their
relative predictive value, each factor was subdivided into
two to four levels and given a weighted score of between 1
and 8. POSSUM outperformed APACHE II scoring in the
prediction of postoperative death and morbidity amongst
177 patients admitted to a surgical high-dependency unit
(Jones et al, 1992).
However, the general application of POSSUM to the
totality of a UK general surgical population has been questioned by Bann and Sarin (2001), who studied 521 oper-

ations performed on 501 patients. In total, 162 of these

were classified as emergency and 342 as elective; the
remaining 17 operations were performed on transferred
patients. A complete POSSUM score was only obtained in
155 patients (29.8). Bann and Sarin (2001) concluded
that this evaluation cast serious doubt on the suitability of
POSSUM for use in audit of general surgeons. In particular, exclusion of day cases and children from POSSUM, 48%
of the workload, along with a blanket approach to preoperative investigation for inpatient treatment that was not
in keeping with hospital guidelines, were significant weaknesses in the use of POSSUM.
The major disadvantage of the original POSSUM prediction equation is a tendency to overpredict patient death
in low-risk general surgery. Whiteley et al (1996) found
that the bulk of the overprediction occurred in the group
at lowest risk (predicted mortality 10% or less), in which
death was overpredicted by a factor of six. The authors
found that the original POSSUM predictor equation for
mortality returns a minimum predicted mortality of
1.08%, much greater than that expected for a fit patient

Risk

TABLE 3.5 PREOPERATIVE AND

OPERATIVE FACTORS SCORED
TO CALCULATE POSSUM
Physiological
Age
Cardiac history
Electrocardiogram
report
Respiratory history
Blood pressure
Pulse rate
Glasgow Coma Scale
Haemoglobin
White cell count
Urea
Sodium
Potassium

Operative
Operative complexity
Multiple procedures
Blood loss
Peritoneal contamination
Extent of malignant spread
Elective versus emergency
surgery

POSSUM, Physiological and Operative Severity Score for the

enUmeration of Mortality and morbidity; P-POSSUM,
Portsmouth Physiological and Operative Severity Score for the
enUmeration of Mortality and morbidity.

having minor surgery. Whiteley et al (1996) used logistic

regression on data from a set of 1485 surgical episodes
to generate a local predictor equation for mortality. This
gave a predictor equation that fitted well with the
observed mortality rate and gave a minimum predicted
risk of mortality of 0.20%. Even this risk of death in
minor surgery (1 : 500) can be seen as an overestimate
(Table 3.6).
Prytherch et al (1998) compared the performance of
the original POSSUM equation with the performance of the
P-POSSUM in 10 000 general surgical cases managed
between 1993 and 1995. The 10 000 patients were
arranged in chronological order and the first 2500 were
used as a training set to produce the modified P-POSSUM
predictor equation. This was then applied prospectively to
the remaining 7500 patients, who were arranged chronologically in five groups of 1500. The original POSSUM mor-

TABLE 3.6 ORIGINAL POSSUM AND

P-POSSUM PREDICTOR EQUATIONS
FOR MORTALITY
POSSUM

P-POSSUM

Equation
ln R/1 R = 7.04 + (0.13
physiological score) + (0.16
operative score)
Ln R/1 R = 9.065 + (0.1692
physiological score) + (0.1550
operative score)

From Whiteley et al (1996).

POSSUM, Physiological and Operative Severity Score for the
enUmeration of Mortality and morbidity; P-POSSUM,
Portsmouth Physiological and Operative Severity Score for the
enUmeration of Mortality and morbidity.

tality equation showed a significant lack of fit between the

predicted mortality and the observed mortality. By contrast,
the P-POSSUM equation gave much better agreement
between expected and observed mortality and has been
proposed as the standard methodology of calculating
expected outcomes against which observed outcomes can
be measured (Table 3.7).
The comparative utility of the two POSSUM equations
in predicting death after gastrointestinal surgery was
examined using 505 patients, 65% of whom had colorectal procedures, 27.5% upper gastrointestinal surgery and
7.5% small bowel surgery (Tekkis et al, 2000). In this comparison, the observed overall operative mortality rate was
11.1% (elective was 3.9% and emergency was 25.1%).
The Portsmouth predictor equation for mortality equation
predicted a mortality rate of 11.3% (P = 0.51). However,
the original POSSUM equation was found to overpredict
death by a factor of two: 21.5% (P < 0.001) (Tekkis et al,
2000).

Physiological scoring and colorectal surgery

In a Saudi Arabian population of rectal cancer patients,
POSSUM failed to predict outcomes accurately in patients
undergoing surgery, P-POSSUM also overpredicted mortality but to a lesser extent (Isbister and Al Sanea, 2002).
The overall POSSUM predicted (using median scores)
morbidity and mortality rates were 35.4% and 6.7%. The
P-POSSUM predicted (using mean scores) mortality
rate was 3.5%. Observed morbidity and mortality rates
were 54.5% and 1.4%.
Tekkis et al (2003a) examined the predictive value of
both POSSUM and P-POSSUM within a population undergoing colorectal procedures using the outcomes of 1017
patients (79% elective and 21% emergency). The overall
operative mortality rate was 7.5% (POSSUM-estimated
mortality rate 8.2%; P-POSSUM-estimated mortality rate
7.1%). Both scoring systems overpredicted mortality in
young patients and underpredicted mortality in the elderly
(P < 0.001). In addition, death was underpredicted by both
equations for emergency cases (Table 3.8).
By contrast, Poon et al (2005) found a good fit between
P-POSSUM-predicted mortality and observed mortality in
patients presenting with colorectal malignant obstruction.
A total of 160 patients were included in the study, of whom
18 died postoperatively. The observed operative mortality
was therefore 11.3%, compared with the P-POSSUM predicted overall mortality of 15%. The observed and predicted
mortality was found to have no significant lack of fit (chisquared = 5.98; degrees of freedom = 3; P = 0.11). POSSUM is also an accurate predictor of 5-year survival in
colorectal cancer (Brosens et al, 2006).
Laparoscopic assisted colectomy presents further
challenges for the predictive value of both POSSUM and
P-POSSUM. In a series of 250 consecutive laparoscopic
assisted colectomies, the observed morbidity rate (6.8%)
was significantly lower than the predicted rates calculated
with an operative score of 4 or 2 (12.4%, P < 0.001; 9.6%,
P = 0.001) but was fully corrected with an operative score
of 1 (7.0%, P = 0.325) (Senagore et al, 2003). In addition, the observed mortality rate (0.8%) was significantly
lower than the expected mortality rates calculated using

75

76

Chapter 3

Perioperative Care

TABLE 3.7 THE ORIGINAL POSSUM EQUATION APPLIED TO 10 000

CASES AND THE P-POSSUM EQUATION APPLIED TO LAST 1500
PATIENTS
Predicted
mortality

No. of
operations

Predicted
deaths

Observed
deaths

Original POSSUM equation applied to 10 000 cases

05
7034
159
515
1879
160
1550
866
227
50100
221
151
0100
10000
697

22
68
120
77
287

P-POSSUM equation applied to last 1500 patients

05
1331
13
515
121
10
1550
37
10
50100
11
8
0100
1500
41

13
13
9
7
42

From Prytherch et al (1998).

POSSUM, Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity;
P-POSSUM, Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality
and morbidity.

either the original POSSUM equation (9.6%, P = 0.001)

or the P-POSSUM equation (3.5%, P = 0.001).
Subsequently, an age-adjusted POSSUM model and a
dedicated (colorectal) CR-POSSUM model (Tekkis et al,
2004) have been developed using a population of 6883
patients undergoing colorectal surgery in 15 hospitals in
the UK, in a 60 : 40% split-sample validation technique.
The subcategories for each factor included in the final CRPOSSUM model were weighted according to odds ratios
derived from multivariate logistic regression analysis. POSSUM variables relating to the structure and process of care

were excluded from the multifactorial models; including

operative blood loss and number of procedures (Table 3.9).
Comparison was made between the performance of PPOSSUM, age-adjusted POSSUM and CR-POSSUM. In this
comparison, the P-POSSUM model overpredicted mortality in the low-risk group of patients (09.9% mortality rate
group) and underpredicted outcome in the higher-risk
group (mortality rate of 2029.9%), a difference that was
statistically significant. The age-adjusted and CR-POSSUM
models fitted the data well, with no significant discrepancies between observed and predicted outcomes, as

TABLE 3.8 POSSUM AND P-POSSUM UNDERPREDICTION OF DEATH

IN EMERGENCY COLORECTAL SURGERY AND ELDERLY PATIENTS
SUBJECTED TO COLORECTAL SURGERY

Operation
Elective
Emergency
Age
< 50
5059
6069
7079
> 80
Total

Observed mortality
(range)

P-POSSUM
mortality

POSSUM
mortality

804
213

3.2 (2.14.7)
23.4 (18.030.0)

3.8
19.5

4.6
16.7

192
149
228
290
158
1017

0.5 (0.12.9)
2.7 (0.76.7)
5.3 (2.79.0)
8.6 (5.712.5)
22.0 (16.029.4)
7.5 (5.99.3)

2.6
3.6
6.2
9.7
12.3
7.1

3.3
6.1
7.5
11.8
12.4
8.2

From Tekkis et al (2003a).

POSSUM, Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity;
P-POSSUM, Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality
and morbidity.

Risk

TABLE 3.9

THE COLORECTAL POSSUM SCORING SYSTEM

Score

Age group (years)

Cardiac failure
Systolic blood pressure (mmHg)
Pulse (beats/min)
Urea (mmol/L)
Haemoglobin (g/dL)
Operative severity score
Operative severity
Peritoneal soiling
Operative urgency
Cancer staging

1
60
None or mild
100170
40100
10
1316

Minor
None or
serous fluid
Elective
No cancer or
Dukes A,B

2
Moderate
> 170 or 9099
101120
10.115.0
1012.9 or 16.118

Local pus

Dukes C

3
6170
Severe
< 90
> 120 or < 40
> 15.0
< 10 or > 18

4
7180

8
81

Intermediate
Free pus
or faeces
Urgent
Dukes D

Major

Complex major

Emergency

From Tekkis et al (2004).

Colorectal POSSUM equation: ln[R/(1 R)] = 9.167 + (0.338 PS) + (0.308 OSS), where PS is the total Physiological Score and OSS is the total
Operative Severity Score.
CR-POSSUM, Colorectal POSSUM; POSSUM, Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity.

evidenced by the calibration plot (Figure 3.2) (Tekkis et al,

2004). Similar observations have now been reported when
POSSUM, P-POSSUM and CR-POSSUM were compared
(Ramkumar et al, 2006).
Al-Homoud et al (2004) compared the accuracy of two
predictive models based on ASA grade (the ACPGBI
Colorectal Cancer model and the Malignant Bowel
Obstruction model) with the CR-POSSUM model based on
physiological and operative scoring. The test population
consisted of the 16 006 patients with diseases of the colon
and rectum who were included in the three multicentre

UK-based studies that were used to develop the three prognostic models (Al-Homoud et al, 2004). For each of the
three models, discrimination (as shown by the area under
the ROC curve), was similar in the ACPGBI CRC (77.5%)
and MBO (80.1%) models but was higher in the CRPOSSUM model (89.8%). All three models fitted the data
well, with no significant discrepancies between the
observed and predicted mortality, as tested by the
HosmerLemeshow c statistic (Table 3.10).
The authors concluded that all three predictive models
can be used in everyday practice for preoperative counselling

50
Observed mortality

Operative mortality (%)

40

P-POSSUM
Age-adjusted POSSUM
CR-POSSUM

30

20

10

0
04.9

59.9

1019.9

2029.9

30100

0100

Risk of mortality (%)

Figure 3.2 Calibration of the three Physiological and Operative Severity Scores for the enUmeration of Mortality and morbidity
(POSSUM) models according to the risk of mortality: Portsmouth (P)-POSSUM, age-adjusted POSSUM and colorectal (CR)POSSUM. Each bar represents the mean observed or predicted in-hospital operative mortality rate; error bars indicate the 95%
confidence interval for observed mortality. From Tekkis et al (2004).

77

Chapter 3

Perioperative Care

TABLE 3.10 COMPARISON OF MODEL PERFORMANCE BETWEEN

ACPGBI CRC, MBO AND COLORECTAL-POSSUM SCORING SYSTEMS
Model performance (validation set)
Study
ACPGBI CRC
MBO
CR-POSSUM

Discriminationa
77.5% (1.6%)
80.1% (1.9%)
89.8% (1.1%)

Calibrationb
5.98, P = 0.649
7.606, P = 0.473
5.01, P = 0.756

O : E mortalityc (%)
7.5 : 7.5
14.3 : 13.5
5.7 : 5.7

From Al-Homoud et al (2004).

a
Discrimination is measured by the area under the receiveroperator characteristic curve (standard error):
higher values represent better model discrimination.
b
Calibration is measured by the HosmerLemeshow c statistic (8 degrees of freedom): smaller values
represent better mode calibration.
c
O : E = Observed to expected mortality in the validation set.
ACPGBI, Association of Coloproctology of Great Britain and Ireland; CRC, colorectal cancer; CR-POSSUM,
Colorectal POSSUM; MBO, malignant bowel obstruction; POSSUM, Physiological and Operative Severity
Score for the enUmeration of Mortality and morbidity.

of patients and their carers, as a part of the process of

informed consent. In addition, they can be employed to
compare outcomes between multidisciplinary CRC teams
and therefore are a powerful tool not only for the purposes
of consent, but also for audit, research, training and
revalidation (Al-Homoud et al, 2004).

Comparative audit
Between national health systems
Comparison between national health-care systems can be
explored using risk-adjusted data as defined by P-POSSUM
(Bennett-Guerrero et al, 2003). Using Mount Sinai Hospital
as the US centre and Queen Alexandra Hospital and St
Marys Hospital Portsmouth as the UK centres, two comparative populations of surgical patients were identified.
Among the 1056 patients treated in the US, POSSUM physiology scores ranged from 12 to 42 and the operative severity scores from 6 to 37. For the 1539 patients treated in the
UK, respective POSSUM scores ranged from 12 to 52 and
from 9 to 40. The severity of the operations performed in
each country was similar between groups: the US cohort
had a mean (s.d.) (median, interquartile range) operative
severity score of 16.7 (5.7) (17, 1320) and the UK cohort
16.5 (6.2) (16, 1120) (P = 0756). Overall, the mean (s.d.)
(median, interquartile range) postoperative length of stay
in hospital was slightly lower for patients in the US cohort
[10.3 (12.6) (8, 610) days] compared with that for the
UK cohort [11.8 (11.6) (9, 514) days] (P < 07001)
(Bennett-Guerrero et al, 2003). Within both the US and
the UK cohorts, an increase in risk estimated by P-POSSUM
predicted an increase in observed mortality rate (P <
07001). However, for any given risk level (Figure 3.3), the
mortality rates were significantly higher in the UK cohort
than in the US cohort [odds ratio 4.50 (95% CI 2.817.19);
Z = 6725; P < 07001) (Bennett-Guerrero et al, 2003).
Although these differences cannot be generalised to the
entire US and UK health-care systems, these findings
should stimulate further exploration into potential causes

100
UK cohort
US cohort

90
Model-based risk of death (%)

78

80
70
60
50
40
30
20
10
0

10

20

30

40

50

60

70

80

90 100

P-POSSUM-estimated risk of death (%)

Figure 3.3 Risk-adjusted mortality rates for US (n = 1056)

and UK (n = 539) cohorts based on the multivariate logistic
regression model. The relationship between the risk of death
predicted by the Portsmouth Physiological and Operative
Severity Score for the enUmeration of Mortality and
morbidity (P-POSSUM) and the risk-adjusted mortality rates
in each of these cohorts based on the multivariate logistic
regression model is shown. From Bennett-Guerrero et al
(2003).

and strategies to improve patient management (BennettGuerrero et al, 2003).

A similar exploration of the utility of POSSUM, P-POSSUM and CR-POSSUM to health care in nine hospitals in
Cleveland, Ohio, was carried out by Senagore et al (2004).
A total of 890 colon cancer resections were studied; resections per institution ranged from 13 to 437. The observed
mortality rate ranged from 0.8% to 15.4% among the

Risk

institutions, with an overall operative mortality of 2.3%.

The POSSUM, P-POSSUM and CR-POSSUM predicted mortality was 10.7%, 11.2% and 4.9%, respectively. The POSSUM and P-POSSUM models overpredicted mortality in all
institutions (P < 0.01), whereas the CR-POSSUM demonstrated an observed over expected hospital mortality ratio
of > 1 in three institutions. It might be that a recalibration
process is required in order for POSSUM scoring to accurately reflect US mortality surgical outcomes (Senagore
et al, 2004).
Between institutions
In the US, Veterans Affairs (VA) medical centres, with a
centralised administration and data collection process, are
uniquely able to compare the surgical outcomes of different institutions. This process is the National VA Surgical
Quality Improvement Program (NSQUIP). This audit
encompassed a surgical database of 417 944 major surgical procedures from 123 VA medical centres that recorded
presurgical risk factors, process of care during surgery and
outcomes 30 days after surgery (Khuri et al, 1998). Logistic
regression analysis was used to develop the predictive models for surgical death and complications. In this logistic
regression model, surgical death and complications are the
dependent variables; the presurgical risk factors (Table
3.11) are the independent variables.
Using this model, comparisons of expected and observed
mortality in each institution identified low and high outlier hospitals for 30-day mortality rates for all surgical
procedures are identified (Figure 3.4).
Hospitals with consistently low outlier status are commended and encouraged to share with the NSQIP (which
subsequently disseminates this information to the rest of
the medical centres) the processes and structures that these
hospitals consider to have contributed to their good performance. Various levels of concern are raised about high

outlier hospitals and suggestions are forwarded regarding

internal and external reviews to verify and improve outcomes of surgery at these hospitals (Khuri et al, 1998).
Subsequent analysis has shown that the NSQUIP model
of risk adjustment can be applied to other non-federal US
hospitals (Fink et al, 2002).

BEFORE

Average rank
1
2
3.3
4.3
5
7
7.3
11
11.3
11.5
12.3
14

From Khuri et al (1998).

ASA, American Society of Anesthetists; BUN, blood, urea,
nitrogen, DNR, do not resuscitate; SGOT, serum glutamic
oxaloacetic transaminase; WBC, white blood cells.

Hospital
%
Code
0.0
A

p
0.026

Rank
1

Hospital
O/E
Code
B
0.28

Rank
1

0.0001

0.6

0.48

0.020

0.7

0.49

0.030

1.1

0.50

0.006

1.2

0.51

0.012

1.2

0.52

0.014

1.4

0.62

0.0005

1.5

0.69

0.006

1.5

0.70

0.009

1.6

10

0.72

10

0.033

1.7

11

0.77

11

0.026

1.9

12
Misclassified by
unadjusted
mortality rate

BEFORE

AFTER

High outlier surgical services ranked High outlier surgical services ranked by
by observed 30-day mortality rate (%) risk-adjusted O/E ratios for 30-day mortality

p
0.035

TABLE 3.11 ORDER OF ENTRY OF MOST

PREDICTIVE PREOPERATIVE RISK
FACTORS IN MORTALITY MODELS FOR
NON-CARDIAC SURGERY
Risk factor
Serum albumin
ASA class
Disseminated cancer
Emergency operation
Age
BUN > 40 mg/dl
DNR
Operation complexity score
SGOT > 40 IU/mL
Weight loss > 10% in 6 months
Functional status
WBC > 11 000/mm3

AFTER

Low outlier surgical services ranked

Low outlier surgical services ranked by
by observed 30-day mortality rate (%) risk-adjusted O/E ratio for 30-day mortality

Hospital
%
Code

Hospital
O/E Rank
Code
K
1.23 111

4.0

107

0.036

4.1

108

1.33

112

0.017

4.2

109

1.34

113

0.014

4.2

110

1.35

114

0.002

4.3

111

1.37

115

0.015

4.3

112

1.37

116

0.016

4.3

113

1.40

117

0.011

4.4

114

1.46

118

0.003

4.5

115

1.46

119

0.031

4.6

116

1.48

120

4.7

117

1.50

121

0.001
0.006

Rank

4.8

118

1.68

122

0.001

4.9

119

2.31

123

0.0007

4.9

120

0.00007

5.2

121

0.007

5.3

122

0.007

7.1

123

Misclassified by
unadjusted
mortality rate

Figure 3.4 Low (panel A) and high (panel B) outlier

hospitals in 30-day mortality rates for all surgical procedures
performed during FY97. Within each panel, the hospitals
rankings by adjusted and unadjusted mortality rates are
compared. Hospitals appearing in both rankings are
connected with a line. In the columns showing the riskadjusted mortality rates, the O/E ratios shown are those that
are significantly different from one at the 90% confidence
limits. In the columns showing the unadjusted mortality
rates, a probability value is calculated that refers to the test
comparing each hospitals observed mortality rate to the
observed mortality rate of all hospitals combined (P < 0.05).
From Khuri et al (1998).

79

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Chapter 3

Perioperative Care

Between surgeons
Human nature is, however, less interested in institutional
performance than in the question Who is the surgeon who
is least likely to kill me and most likely to fix me?
This question fits with the moves in recent years to
increase openness and transparency in the delivery of
health care. In the UK, this has been accelerated by the
Bristol Royal Infirmary inquiry into paediatric surgical
deaths (Bridgewater, 2005). This inquiry included 198 recommendations, of which two stated that patients must be
able to obtain information on the relative performance of
the Trust and of consultant units within the Trust. This led
to an increasing belief that the interests of the public and
patients would be served by publication of individuals surgical performance in the form of postoperative mortality
(Keogh et al, 2004).
In the US, outcomes attributable to individual cardiac
surgeons in New York were dragged into the public arena
in December 1991. The New York department of health
was sued by a newspaper, Newsday, using the states
Freedom of Information Law. The lawsuit was lost and
the surgeon-specific mortality data was given to Newsday,
and published in December 1991 (Chassin et al, 1996).
Interestingly no movement of patients away from hospitals
with high mortality rates has occurred. Thus, in 1989,
8.7% of all patients undergoing CABG were treated at hospitals whose risk-adjusted mortality rates were significantly
higher than the State average, and 15.7% were treated at
hospitals with significantly lower rates. The comparable figures in 1993 were 9.5% and 17.0%, respectively (Chassin
et al, 1996).
Recently, the Freedom of Information Act has become
law in England and Wales. This gives individuals the right
to obtain data from public organisations. Under the Act, it
is inevitable that individual surgeon data will come into the
public domain. Some individual hospitals are responding
by putting results on the internet (Bridgewater, 2005). If
it is to be useful to the public and fair to individual surgeons
(Bridgewater, 2005), mortality data:

should be easy to understand

needs to be based on robust data
must compare like with like, i.e. risk adjusted
should not engender a surgical culture of avoiding highrisk patients.

Comparison of individual surgeon outcomes after colorectal resection using unadjusted data demonstrates wide
variations: morbidity varying from 13.6% to 30.6% and
mortality from 4.5% to 6.9%. However, risk-adjusted
analysis based on POSSUM scores demonstrated that the
predicted outcomes expected for each surgeons casemix
were very similar to those observed (Sagar et al, 1996).
Tekkis et al (2000) similarly found that the mortality rates
among the four surgeons varied from 7.6% to 14.7%. The
observed-to-expected ratio of deaths for the original POSSUM equation was only 0.45 to 0.56 but for P-POSSUM
the predictor equation for mortality was close to unity
(0.905 to 1.067) for all four surgeons.
Keogh et al (2004) point out that although the surgeon
plays an important role in surgical outcome, so do many
other important factors. These include which patients are

selected for surgery, which is affected by socioeconomic status of the local population, prevalence of comorbidities,
threshold of referral from the general practitioner and
threshold of acceptance by the surgeon. In addition, there
is the influence of the entire health-care infrastructure
the anaesthetist, the intensive care physician, the surgical/
high-dependency nurse, the junior surgical staff enmeshed
with local standards of anaesthesia, surgery and intensive
care; adequacy of facilities and staffing levels; attitudes
towards training; interpersonal relationships between staff;
and the geographical layout of the unit (for example, in
some units the wards are so far from the theatre that surgeons have no time to check-up on ward patients between
surgery cases).
In the authors view this complex interaction cannot be
reflected in surgeon-specific outcomes. We agree with the
approach taken in the VA medical centres outlined above,
i.e. the National VA Surgical Quality Improvement
Program (NSQUIP; Khuri et al, 1998). This approach
overtly recognises that the performance of a surgeon cannot be separated from that of his or her institution, as quality is highly dependent on institutional systems. For
health-care systems to develop these comparative audits,
investment is required in valid data collection and processing that generates meaningful institutional outcomes, which can in turn be used for constructive service
improvement.

COMMUNICATING RISK:
DISCLOSURE OF RISK
The right to free and informed consent is an international
obligation placed on all health-care workers (Moumjid and
Callu, 2003). The new medical conversation integrates risk
communication into the doctorpatient consultation
(Edwards, 2003). The information offered should be simple, relevant, and responsive to the needs and values of the
individual patient. Difficult and complex risks will require
a series of consultations, at the end of which both surgeon
and patient might have to share the same uncertainties as
to the outcome of the proposed procedure (Edwards,
2003).
The first barrier, for both professional and patient, is in
understanding the arithmetic size of the proposed risk:
moving from innumeracy to insight (Gigerenzer and
Edwards, 2003). Three classes of numerical representation
that lead to confusionsingle-event probabilities, conditional probabilities and relative risksare discussed by
Gigerenzer and Edwards (2003). In their account they
consider ways in which alternative representations might
promote insight (Table 3.12).
In most colorectal surgical consultations, single-event
probabilities are presented in the course of discussing a surgical intervention. Thus, for a patient being counselled for
elective colorectal cancer resection (5% mortality), it would
be appropriate to inform the patient and his or her family
that, of every 20 patients admitted for resection, one
patient dies within 30 days of the procedure. However,
presenting risk to a patient is not only about the numerical data but also the context in which it is presented.
For effective risk communication, the colorectal surgeon
has to display both competence and a caring approach

Risk Management

TABLE 3.12 EXAMPLES OF CONFUSING STATISTICAL INFORMATION, WITH ALTERNATIVES

THAT FOSTER INSIGHT
Type of information
Single-event probabilities

Examples
You have a 30% chance of a side effect
from this drug

Conditional probabilities

The probability of a positive test result if

the patient has the disease (sensitivity)
The probability of a negative test result
if the patient does not have the disease
(specificity)
The probability of the disease if the patient
has a positive test result (positive
predictive value)
If four out of every 1000 women (aged 40
or older) who do not undergo
mammography screening die of breast
cancer, compared with three out of every
1000 who are screened, the benefit is
often presented as a relative risk:
Mammography reduces breast cancer
mortality by 25%.

Relative risks

How to foster insight

Use frequency statements: Three
out of every 10 patients have a
side effect from this drug
Use natural frequencies, alone or
together with conditional
probabilities

Use absolute risks, alone or together

with relative risks: In every 1000
women who undergo screening
one will be saved from dying of
breast cancer.
Use the number needed to treat or
harm: To prevent one death from
breast cancer, 1000 women need
to undergo screening for 10 years.

From Gigerenzer and Edwards (2003).

(Paling, 2003). Other important communication strategies

described by Paling (2003) include:

Avoiding the use of descriptive terms only (e.g. terms such

as low risk).
Using standardised vocabulary (very common, common, uncommon, rare and very rare).
Using a consistent denominator (e.g. 40 out of 1000 and
5 out of 1000, rather than 1 in 25 and 1 in 200). Many
patients can mistake which is the greater risk if different
denominators are used.
Using absolute numbers.
Using visual aids for probabilities.

RISK MANAGEMENT
MECHANICAL BOWEL PREPARATION
The need for some method of bowel preparation was
proposed soon after the introduction of colonic resection
rather than colostomy for the management of large bowel
disease (Reybar, 1844; Wilkie, 1938). In the past, clinicians relied upon a period of starvation (allowing liquids
only for 45 days), purgation (usually with magnesium
salts), enemata and rectal washouts (Rogers, 1971, Miller,
1975). During the 1970s and 1980s new techniques were
introduced, largely to improve patient compliance and
reduce the length of preoperative hospital stay (Huddy
et al, 1990; Lee et al, 1996). In this section we present a
detailed account of mechanical bowel preparation for
patients undergoing colonic resection and/or endoscopic
inspection of the colon. This is because for many colorectal surgeons in the USA and the UK, colonic preparation

continues to be a cornerstone of modern elective colorectal surgery in preventing sepsis (Nichols et al, 2005).
Others, however, take an entirely contrary view in which
mechanical bowel preparation before elective colonic surgery is viewed as injurious to the patient (Fearon et al,
2005).

Distal preparation
Enemata are essential if sigmoidoscopy is uninformative
because of gross faecal residue. This is particularly relevant
to pouch surveillance after restorative proctocolectomy as
well as for examination of the rectum after ileorectal anastomosis. Devlin et al (1979) compared dioctyl sodium sulphosuccinate (1% w/v) with sodium acid phosphate (10%) and
with soap enemata (5% w/v). All three preparations were
equally successful for rigid sigmoidoscopy. Although the
dioctyl and phosphate enemata were more expensive than
the soap enemata, the added cost of the proprietary preparations was justified by reduced nursing time. An outpatient
flexible sigmoidoscopy is often desirable in a patient with a
suspected carcinoma in the sigmoid which cannot be visualised or biopsied with the rigid instrument. In this situation,
a disposable phosphate enema is superior to the small volume
Microlax (Silverman and Keighley, 1985).

Colonoscopy and colonography

Polyethylene glycol electrolyte oral lavage was reported
to be superior to conventional purgation with enemas
(Ernstoff et al, 1983). By contrast, radiologists find that
whole gut irrigation leaves the colon too wet for optimum
mucosal coating (Skucas et al, 1976; Backran et al, 1977;
Lee et al, 1981; Ernstoff et al, 1983). Traditional mechanical preparation may influence the histology of the colon

81

82

Chapter 3

Perioperative Care

and can be associated with flattening of the surface epithelial cells, goblet-cell depletion and increased oedema in the
lamina propria (Gaginella and Phillips, 1976; Saunders
et al, 1977; Meisel et al, 1977). By contrast, GoLytely was
associated with minimal changes on light microscopy
(Pockros and Foroozan, 1985). Fa-Si-Oen and Penninckx
(2004) compared full-thickness surgical colonic biopsies
from 20 patients who received a normal meal the night
before surgery with biopsies from 20 patients that had
undergone colonic cleansing with polyethylene glycol.
After assessing five microscopic criteria of damage to the
colonic wall the authors concluded that polyethylene glycol caused no significant additional tissue damage. Others
have reported that sodium phosphate can produce aphthous ulcers and that they are more common than in
patients prepared with polyethylene glycol electrolyte solutions (Hixson, 1995; Zwas et al, 1996). Nevertheless, these
lesions have not been observed elsewhere (Curran and
Plosker, 2004) either at endoscopy or from resection specimens (Kolts et al, 1993; Cohen et al, 1994; Oliveira et al,
1997). Furthermore, oral whole-bowel irrigation is often
poorly tolerated and cannot be completed in a high proportion of patients (Burbridge et al, 1978; King et al, 1979;
Thomas et al, 1982; Ernstoff et al, 1983; Adler et al, 1984;
DiPalma et al, 1984; Kohler et al, 1990; Cohen et al, 1994;
Chia et al, 1995; Oliveira et al, 1997).
Colonoscopy preparation with sodium phosphate has
been reported as superior to oral polyethylene glycol electrolyte lavage (Adams et al, 1994; Cohen et al, 1994; Chia
et al, 1995; Golub et al, 1995; Hookey et al, 2004; Curran
and Plosker, 2004). Recently, however, a more complex triple regimen [senna syrup (sennoside B), Picolax
(sodium picosulphate), and Klean Prep (polyethylene glycol
3350)] appeared to be superior to Fleet Phospho-soda for
colonoscopy preparation, achieving better colonic cleansing (triple regimen 73%; Fleet phospho-soda 57%; P =
0.037) (Chilton et al, 2000). Subsequently, a comparison of
bowel cleansing efficacy in patients having colonoscopy, has
been made between the standard polyethylene glycol-electrolyte solution based on the GoLytely formulation (PEGEL1; Klean-Prep); a sulphate-free PEG-EL solution based
on the NuLytely formulation (PEG-EL2, Endofalk); and a
sodium phosphate preparation (NaP, Fleet Phospho-Soda).
Among 185 patients randomly assigned to the three therapies PEG-EL1 (Klean-Prep) was significantly superior to PEGEL2 (Endofalk) and NaP (Fleet Phospho-Soda) in achieving
effective cleansing of the entire colon prior to colonoscopy
(Ell et al, 2003).
In a comparison of patient preference between the techniques of computed tomography (CT) colonography and
conventional colonoscopy, bowel preparation was the feature of both techniques most disliked by the patients studied (Ristvedt et al, 2003). Lefere et al (2002) examined the
feasibility of detecting colonic polyps when a preparation
of reduced colonic cleansing had been employedfaecal
tagging. The technique of faecal tagging was better tolerated than conventional polyethylene glycol preparation and
also improved colonographic differentiation of polyps from
residual stool. In virtual magnetic resonance colonography, faecal tagging is employed by either making the stool
bright (Gd-based MR contrast agent) in conjunction with

a bright Gd-based enema or making the stool dark by

administering barium sulphate with each of four main
meals 36 hours before the examination (Debatin and
Lauenstein, 2003). In the second strategy, the colon is
distended by a water enema. Intravenously administered
paramagnetic contrast then renders the colonic wall and
colorectal mass lesions bright. Therefore in the future
colonography without colonic cleansing offers greater
patient acceptability in diagnostic colonic studies (Herfarth
and Schreyer, 2003).

Traditional preoperative methods

Traditional bowel preparation, which involves starvation,
purgation, enemata and washouts, is time consuming,
exhausting to the patient and demanding on nursing time,
requiring supervision for some days before operation
(Duthie et al, 1990; Santos et al, 1994):

Food intake is discontinued for a variable period. Patients

are encouraged to drink plenty, both to avoid dehydration
and to overcome the feeling of hunger (Binder, 1977;
Fingl and Freston, 1979). To avoid faecal residue, only
clear fluids should be consumed, because low-residue
diets result in the production of some faeces (Winitz et al,
1966; Cooney et al, 1974; Johnson, 1974). Milk products
should not be allowed and oral iron therapy must be
discontinued (Teague and Manning, 1977). This form
of preparation is unsuitable for people with diabetes.
Purgatives: magnesium salts have been used extensively
in the past. These reduce sodium and water absorption
and produce some secretion into the lumen of the small
bowel, hence a large-volume hyperosmolar fluid load is
presented to the caecum. Consequently, although magnesium salts produce excellent clearance of the right
colon, they cause considerable abdominal colic (Forth
et al, 1972; Jauch et al, 1975). The dose of magnesium
sulphate varies from 5 to 15 g; in some institutions 10 mg
is given 2-hourly on the day before operation. Magnesium
citrate causes less colic and is usually effective using only
two 13 g doses. Sodium sulphate has a similar action to
magnesium citrate and inhibits sodium reabsorption
(Tsang et al, 1992).
Senna compounds are activated by colonic bacteria and
have no laxative effect until they reach the large bowel,
hence clearance of the right colon is inferior to that
achieved with magnesium salts (Hardcastle and Wilkins,
1970). Senna also causes vigorous mass contractions in
the colon, which result in some discomfort (Laurence,
1973). Sodium picosulphate (10 mg), which is often
given with magnesium citrate (Picolax), is another purgative whose action depends on bacterial activation. The
anthraquinones such as bisacodyl or oxyphenisatin may
be given orally and are also activated by colonic bacteria.
They may be given rectally as a stimulant enema.
Castor oil may be used as a stool softener (Levy et al,
1976; Beck et al, 1985) in a dose of 45 mL on the
evening before operation, with saline enemata and
a fluid diet (Margulis, 1967; Barnes, 1968; Irwin et al,
1974). Alternatives to castor oil include dioctyl sodium
sulphosuccinate (100 mg 8-hourly for 34 days prior to
the enemata) and washouts.

Risk Management

Most traditional preparations conclude with enemata and a

washout. Saline enemata are said to cause less electrolyte
disturbance than tap water or soap enemata (Turrell and
Landau, 1959; Tyson and Spaulding, 1959; Mikal, 1965).
Phosphate or bisacodyl enemata stimulate mass contraction of the rectosigmoid. Corman (1993) considers that the
tap water enema is the most important part of bowel preparation and should be continued until the returns are completely clear. The most aggressive form of distal clearance
is by the Henderson or Suda irrigating machines or using
pulsed irrigation evacuation (Kokoszka et al, 1994). Like
most forms of distal preparation, the quality is largely determined by the commitment of the nurse. Both De Lacey et al
(1982) and Lee and Ferrando (1984) came to the conclusion that these forms of rectal washout had no influence
on quality of preparation for barium enema. Furthermore,
rectal washout produced a wet colon which resulted in poor
mucosal coating by barium.

Nasogastric whole-bowel irrigation

Irrigation of the bowel with an electrolyte solution was
proposed for the treatment of cholera (Hewitt et al, 1973)
and for the investigation of bidirectional ionic flux (Love
et al, 1968). The technique was subsequently modified as
a method of bowel preparation. The procedure involves
passing a fine nasogastric tube. Intravenous metoclopramide may minimise nausea and accelerate gastric
emptying (Crapp et al, 1975). Advancement of the tube
through the pylorus does not alleviate distension and
nausea (Christensen and Kronberg, 1981).
Walls (1980) recommended adding 90 g of salt to 10 L
of tap water and infused at a constant rate. After about 30
minutes, the patient usually wants to defecate and should
then be seated on a commode. The preparation should not
be terminated until completely clear fluid has been passed
for at least half an hour. It is usually necessary to infuse
1012 L of fluid and the procedure takes between 4 and 6
hours. If nothing is passed after 1 hour, if the patients
abdomen becomes distended or if there is repeated vomiting, the infusion should be stopped, to avoid causing
obstruction. Patients do not like this form of bowel preparation (Downing et al, 1979) and, although whole-bowel
irrigation still provides a high-quality bowel preparation,
it is not superior to polyethylene glycol electrolyte solution
or sodium phosphate with bisacodyl (Wolters et al, 1994).
Isotonic saline (Hewitt et al, 1973), caused fluid and
sodium retention with potassium loss and was contraindicated in patients with renal, cardiac or hepatic failure
(Crapp et al, 1975). Gilmore et al (1981) recommended a
solution containing less sodium (125 mmol/L) but including potassium and bicarbonate. Ringers lactate was therefore recommended by those still enthusiastic about the
technique (Wolters et al, 1994), but water retention of
between 1 and 8 L is a serious complication in patients with
cardiac or renal disease.
Combining an osmotic agent with saline irrigation
reduced the volume required (Donovan et al, 1980).
Furthermore, the fluid and sodium retention which accompanied saline lavage alone was eliminated when an osmotic
agent was used before the saline irrigation (Minervini et al,
1980a). A balanced electrolyte solution with polyethylene

glycol as an osmotic agent was developed and achieved

an excellent quality of mechanical preparation with only
45 L of fluid, so that the procedure could be completed
in 23 hours without disturbance of fluid or electrolyte
balance (Ambrose et al, 1983b).
Nasogastric whole-bowel irrigation using an osmotic
agent and a balanced electrolyte solution is an excellent
method of preparing the colon (Kohler et al, 1990). It is
better than traditional bowel preparation (Christensen and
Kronberg, 1981) but the method is disliked by patients.
Furthermore, the technique is contraindicated in acute
colitis, in megarectum with gross constipation and in
obstructing tumours of the large bowel. An alternative
approach, which reduces the duration of preparation, is to
use Picolax before whole gut irrigation (Grace, 1988).

Oral whole-bowel irrigation

Electrolyte solution
Levy et al (1976) proposed the use of an oral electrolyte
solution by mouth. Patients found this extremely nauseating and four of 37 patients could not complete the preparation. Not surprisingly, patients also complained of
abdominal fullness. However, they found oral irrigation less
of an ordeal than traditional preparation.
Osmotic agents
Newstead and Morgan (1979) introduced the concept of
drinking an osmotic agent. They chose the oligosaccharide
mannitol because this is not absorbed during rapid transit
through the small bowel, thereby achieving an osmotic
catharsis (Hindle and Code, 1962; Nasrullah and Iber,
1969; Kreel, 1975; Nagy, 1981). However, it soon became
apparent that mannitol was associated with dehydration
and sodium loss (Gilmore et al, 1981). There were also
reports of occasional fatal explosion with mannitol bowel
preparation, probably due to methane production as a
result of its fermentation by Escherichia coli (Bigarde et al,
1979; Keighley et al, 1981; Taylor et al, 1981; Zanoni et al,
1982). Mannitol was therefore discontinued.
Electrolyte solution and osmotic agents
Gilmore et al (1981) suggested that if osmotic agents were
combined with an electrolyte solution there should be no
fluid and electrolyte disturbance. A formulation that used
sodium sulphate was developed (Davis et al, 1980).
Sulphate inhibits sodium reabsorption, thereby minimising
sodium and water retention. The mannitol was replaced by
polyethylene glycol, an inert, non-absorbable, non-fermentable compound that acted as the osmotic agent. The
formulation also included sodium bicarbonate to prevent
acidosis and some sodium supplements to minimise potassium loss. The formulation can be prepared in any pharmacy but it is now marketed in many different preparations,
such as sulphate free, NuLytely, Calyte and CP100, many of
which are flavoured for improved palatability (Berry and
DiPalma, 1994; Diab and Marshall, 1996).
Polyethylene glycol electrolyte solutions are safe and
generally achieve a high quality of preparation (Kolts et al,
1993; Lazzaroni et al, 1993; Chia et al, 1995). However,
4 L of fluid must be taken, which some patients find difficult to tolerate (Goldman and Reichelderfer, 1982; Thomas

83

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Chapter 3

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et al, 1982; Girard et al, 1984). There is no need to administer metoclopramide (Rhodes et al, 1978) but bisacodyl
reduces the fluid intake from 4 to 2 L, which is easier for
elderly patients to cope with, without compromising the
quality of preparation (Adams et al, 1994). The risk of
explosion is related only to the amount of faecal residue in
the colon and there is no disturbance in electrolyte balance
or acidosis (Ambrose et al, 1983b). The preparation is more
efficient than conventional preparation for colonoscopy
(Rhodes et al, 1977; Thomas et al, 1982; Ernstoff et al,
1983; DiPalma et al, 1984; Beck et al, 1985) but all forms
of gut lavage seem to be disappointing when used for barium enema examination (Skucas et al, 1976; Backran et al,
1977; King et al, 1979; Ernstoff et al, 1983). Completion
of a 4-L preparation is only achieved in 5065% of patients
and causes considerable nausea and distress to many
patients (Vanner et al, 1990; Marshall et al, 1993; Adams
et al, 1994; Chia et al, 1995; Golub et al, 1995).
Oral irrigation with electrolyte and polyethylene glycol
is preferred by most patients to conventional preparation
and nasogastric whole-bowel irrigation (Ambrose et al,
1983b). However, in our experience, compliance is much
higher with Picolax or sodium phosphate (Takada et al,
1989; Yoshioka et al, 1998). Outpatient compliance to the
polyethylene glycol electrolyte solution is variable. Many
elderly patients will not drink a sufficient volume to ensure
that the faecal effluent is completely clear. The technique
may also precipitate large bowel obstruction.

Purgation alone
Sodium picosulphate and magnesium
citrate (Picolax)
Sodium picosulphate with magnesium citrate (Picolax)
gives better results than either sennosides or mannitol
because the right colon is cleared better (Lee and Ferrando,
1984). In a randomised comparison of sodium picosulphate
with polyethylene glycol electrolyte lavage for colonoscopy,
picosulphate was significantly better, with fewer side effects
and better bowel cleansing (Regev et al, 1998). Picolax is
substantially more effective than preparation with enemas
and washouts (Roe et al, 1984). Tsang et al (1992) found
that Picolax was superior to a balanced oral electrolyte
solution (CP100) but inferior to sodium sulphate, which is
marginally less expensive. Clear fluids for 24 hours seems
essential to achieve an adequate bowel preparation.
Our practice has been to use Picolax exclusively, using
two sachets given 4 hours apart, 24 hours before operation, endoscopy or double contrast barium enema, followed
by clear fluids thereafter. Compliance is good and generally
a high-quality preparation is achieved. Dehydration was
common unless patients were given an intravenous
infusion or encouraged to take extra fluids (Takada et al,
1993; Barker et al, 1992).
Sodium phosphate
Sodium phosphate is marketed as Fleet phospho-soda. Its
advantage is that a much smaller volume is required compared with the polyethylene glycol electrolyte solutions: 45
mL of the highly osmotic cathartic is mixed with 90 mL of
water and taken twice (Chia et al, 1995). The only drawback to sodium phosphate is the small risk of hyperphos-

phataemia and hypocalcaemia. Hyperphosphataemia is

dose related and more common in patients with renal failure (Afridi et al, 1995). Patients may encounter a modest
reduction in serum potassium and increased serum sodium
with sodium phosphate preparation (Lieberman et al,
1996) and it is therefore contraindicated in congestive cardiac failure, ascites and renal failure (Aradhye & Brensilver,
1991).
With the exception of a small colonoscopy study from
California (Marshall et al, 1993), most studies have found
that sodium phosphate was cheaper, better tolerated, more
likely to be completed and more effective than polyethylene
glycol electrolyte lavage for bowel preparation (Vanner et al,
1990; Kolts et al, 1993; Cohen et al, 1994; Chia et al, 1995;
Golub et al, 1995; Hookey et al, 2004; Curran and Plosker,
2004). A transient minor elevation of serum phosphate was
recorded by some, who examined body composition, but
there were no recorded side-effects and calcium levels were
uninfluenced by the preparation. Sodium phosphate is thus
gaining popularity for colonoscopy in the USA because of its
competitive price, ease of administration and greater patient
compliance. It has also been recommended as the preparation
of choice in a consensus statement on bowel preparation for
colonoscopy (Wexner et al, 2006). A trial to compare sodium
phosphate with polyethylene glycol based oral lavage also
reported greater compliance, less pain, fatigue and bloating
with comparable efficacy but both preparations resulted in
a significant decrease in serum calcium (Oliveira et al,
1997). Similarly, in a comparison of sodium phosphate with
sodium picosulphate (Picolax), poor preparation was less
common in the sodium phosphate group (poor/awful 5/76,
9%) than in the picosulphate group (poor/awful 13/73,
18%; P = 0.084) (Yoshioka et al, 2000).

On-table preparation
Antegrade irrigation
Peroperative preparation is a method of ensuring that the
colon is empty prior to primary anastomosis. This procedure may be used either during an emergency operation
for bleeding, localised perforation or obstruction, or when
preoperative bowel preparation is unsatisfactory (Muir,
1968; Dudley et al, 1980).
Indications

The concept of intraoperative irrigation for large-bowel

obstruction stems from the knowledge that staged procedures
are attended by a high mortality and a high permanent
stoma rate, (Hughes, 1966; Fielding and Wells, 1974; Irvin
and Greaney, 1977; Stewart et al, 1984; Phillips et al, 1985).
The aim is therefore to resect diseased bowel and perform a
primary anastomosis after removing all faecal residue from
the proximal colon.
Patients with localised sepsis from a walled-off perforation of the colon constitute a group in whom on-table
lavage might also be advised because conventional bowel
preparation may result in a free perforation. If the proximal colon can be rendered empty, a safe primary anastomosis can be performed (Mealy et al, 1988). In patients
with severe repeated colonic haemorrhage, on-table lavage
should facilitate total gut endoscopy and bleeding lesions
may be more easily identified.

Risk Management

Technique

A large (no. 26) Foley catheter is inserted through a

purse-string suture placed in the caecum, either through
the base of the appendix, if it is still present, or where the
taenia coli converge. Alternatively, and especially if a loop
ileostomy is to be raised a small ileostomy is made in the
terminal ileum (at the site of the proposed stoma) and the
Foley catheter is advanced through an ileostomy purse
string into the caecum for irrigation. The Foley catheter
is attached to an infusion set and a 3-L bag of
Hartmanns solution (Munro et al, 1987). Some authors
use tap water but there is a risk of excessive water absorption if an isotonic solution is not used (Jones and Siwek,
1986; Pollock et al, 1987).
The entire colon, including both flexures, is mobilised, taking great care not to injure the distended and obstructed
bowel or to damage the vascular arcade. The bowel is isolated below the site of obstruction with a tape or curved
aortic clamp, and an on-table rectal washout is performed
until the rectum is completely clean (see below).
The bowel below the obstruction or locally perforated
bowel is divided. The colon is then delivered out of the
wound. Colonic effluent is drained via anaesthetic scavenger tubing, connected to a transparent plastic bag or
a purpose-built unit (Koruth et al, 1985b), inserted into
the proximal colon through the purse-string and secured
by a second nylon tape (see Figure 3.5). Irrigation
through the Foley catheter can now commence. The irrigation fluid should be at room temperature. Jones and
Siwek (1986) use a mercuric perchloride rectal irrigation
at the completion of the proximal colonic lavage. Pollock
et al (1987) use 10% povidoneiodine through the proximal colon as a last wash (Banich and Mendak, 1989).
If anaesthetic tubing is used to collect the distal effluent it
may be necessary to break-up any solid faecal matter in the
descending colon to allow it to pass through the tubing into
the collecting bag and to vent the tubing with a wide-bore
needle if a negative pressure develops in the closed irrigation system. An alternative lavage technique involves opening the colon just above the lesion through a longitudinal
colotomy so that the solid and liquid stool can be rapidly
directed into a bowl held to the side of the wound, the colotomy and colonic lesion both being included in the resected
specimen. The irrigation should continue until clear effluent emerges and the whole procedure should not take any
longer than 20 minutes. A stapled or sutured anastomosis
should be possible with an empty rectum and proximal
colon (Koruth et al, 1985b). Some authors advise decompressing the anastomosis (tube ileostomy or tube caecostomy, depending on the site of enterotomy) by inflating the
balloon after securing the serosa of the bowel to the parietal peritoneum and the catheter to the abdominal wall.
However, we much prefer a loop ileostomy if the bowel
preparation has been successful.
There are several reported series of patients who have had
antegrade on-table colonic irrigation; most of these studies are not confined to patients with acute obstruction but
include those in whom preoperative bowel preparation
was inadequate. The mortality in patients having primary
resection and anastomosis under emergency surgical con-

ditions with on-table lavage ranges from 0% to 17%,

specifically: 3% (Radcliffe and Dudley, 1983), 13%
(Koruth et al, 1985a), 4% (Thomson and Carter, 1986),
3% (Weaver and Khawaja, 1986), 17% (Pollock et al,
1987) and 0% (Maher et al, 1996).
Rectal washout
On-table rectal washout should always be a therapeutic
option when operating on the left colon or rectum.
Accordingly, all patients should be placed in the Lloyd
Davies position and a large (no. 30) Foley catheter inserted
into the rectal ampulla.
Indications

If a stapled rectal anastomosis is used, rectal washout is

advised if the bowel is unprepared or where preparation is
poor, to ensure that the rectal ampulla is free from any faecal material. Passage of a stapling instrument through an
inadequately prepared rectal ampulla increases the risk of
pelvic contamination.
Technique

The rectum is cross-clamped after full mobilisation and, in

the case of rectal cancer, the clamp should be applied just
below the tumour. The washout is performed using a
no. 30 Foley catheter or, if very low, a 50-mL syringe, and
should continue until the effluent is clear of faecal residue
(see Figure 3.6). For mid-rectal cancers, an alternative
technique is to staple the rectum below the tumour, perform the distal washout and then place a second staple
line a further 12 cm distally beyond the first staple line
and divide the bowel at this point through lavaged rectum. Washout with povidoneiodine achieves a significant
reduction in the aerobic counts within the rectal ampulla,
0.3% hypochlorite solution eliminated both aerobes and
anaerobes from the rectal stump (Scammell et al, 1985).
There is no evidence that rectal washout reduces the anastomotic leak rates after low anterior resection (Cade, 1981;
Tagart, 1981).

Efficacy and surgery: the authors view

Bowel preparation is probably still practised by most surgeons performing elective colorectal operations in the
belief that it is a safe technique and that sepsis and anastomotic breakdown may be minimised by operating on
an empty colon (Nichols and Condon, 1971). However,
this concept has been challenged in recent years (Irving
and Scrimgeour, 1987). Thus series that describe good
results following the immediate repair of colonic penetrating trauma without mechanical colonic cleansing,
have brought into question the relevance of elective
bowel preparation (Curran and Borzotta, 1999; Conrad
et al, 2000). Before assuming that mechanical bowel
preparation is desirable, the impact of bowel preparation
on infections, anastomotic dehiscence and safety must
be assessed critically.

Safety
It is important that mechanical bowel preparation is safe
and does not cause unnecessary discomfort or anxiety to

85

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Chapter 3

Perioperative Care

b
Figure 3.5 On-table colonic lavage in progress. (a) An
electrolyte solution at body temperature is being irrigated
through an appendicostomy purse-string and solid faecal
residue is being irrigated from the colon proximal to the
tumour through the anaesthetic scavenger tubing which drains
into a plastic bag below the operating table. (b) Commercially
available device for achieving on-table colonic lavage to
achieve rapid volume irrigation. (c) Commercially available
technique for collecting effluent to minimize contamination
and to provide a method of venting.

Risk Management

Figure 3.6 On-table rectal washout. The

patient is in the LloydDavies position.
Bowel clamps have been placed below
the obstructing lesion. A Foley catheter
has been inserted into the rectal stump.
The rectal stump is being irrigated with
an antiseptic solution.

the patient. Special consideration (Valantas et al, 2004)

needs to be given to elderly patents undergoing bowel
preparation with respect to:

Nursing-home residents with impaired mobility, impaired

sphincter function and coexisting problems with diarrhoea or constipation.
Obtunded patients, who should not be given lavage preparations.
Avoiding magnesium citrate in patients with renal failure.
Not giving a phosphate load to patients with renal, cardiac or hepatic insufficiency.

Vigorous mechanical bowel preparation may occasionally

be complicated by perforation and bacteraemia, hence the
use of bowel preparation should be avoided in acute colitis
and possibly in patients with a localised pericolic abscess
(Galloway et al, 1982).

Reducing the risk of sepsis

Although it is assumed that a clean colon is associated with
a significant reduction in sepsis, the evidence that this is
true among patients having mechanical preparation alone,
without antibiotic cover, is lacking (Burton, 1973). If an
efficient method of bowel preparation is used with antibiotic cover, the quality of bowel preparation is an independent variable in reducing sepsis (Morris et al, 1983).
There are some forms of mechanical bowel preparation,
such as the oligosaccharide mannitol, that may increase
the risk of sepsis (Hares et al, 1981a). Previous clinical

series have suggested that efficient mechanical bowel

preparation will protect against the risk of sepsis if it is
combined with some form of systemic antibiotic cover
(Chung et al, 1979; Gottrup et al, 1985; Panton et al,
1985; Raahave et al, 1986). In this regard, oral wholebowel irrigation or nasogastric irrigation is not necessarily
superior to traditional forms of preparation in minimising
sepsis (Christensen and Kronberg, 1981; Fleites et al,
1985).
But does mechanical bowel preparation have a role in
reducing wound sepsis or anastomotic leaks after colorectal surgery? Jansen et al (2002) report on 102 consecutive
elective right hemicolectomies or extended right hemicolectomies for colorectal cancer. All underwent resection
over a 10-year period without bowel preparation. There
were no leaks, two wound infections and one death (anastomosis intact at autopsy). Vlot et al (2005) reported on
144 patients who underwent an elective (low) anterior
resection between January 1996 and December 2001 and
neither had mechanical bowel preparation nor a covering
loop ileostomy. Anastomotic leakage occurred in seven out
of 144 patients (4.9%). There was a trend toward a higher
leakage frequency in men, in patients with a distal anastomosis, in patients with a stapled anastomosis, and in
patients with a T3T4 tumour or with positive lymph
nodes.
Bucher et al (2005) studied patients scheduled for
elective left-sided colorectal resection with primary anastomosis randomised to preoperative mechanical bowel
preparation (3 L polyethylene glycol) (group 1) or

87

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Chapter 3

Perioperative Care

surgery without mechanical bowel preparation (group 2).

Postoperative abdominal infectious complications and
extra-abdominal morbidity were recorded prospectively.
One hundred and fifty-three patients were included in the
study, 78 in group 1 and 75 in group 2. The overall rate of
abdominal infectious complications (anastomotic leak,
intra-abdominal abscess, peritonitis and wound infection)
was 22% in group 1 and 8% in group 2 (P = 0.028).
Anastomotic leak occurred in five patients (6%) in group
1 and one (1%) in group 2 (P = 0.210). Extra-abdominal
morbidity rates were 24% and 11% for bowel preparation
or no preparation, respectively (P = 0.034). Hospital stay
was longer for patients who had mechanical bowel preparation [mean (s.d.) 14.9 (13.1) versus 9.9 (3.8) days; P =
0.024].

Reducing the risk of anastomotic breakdown

Early evidence from clinical series suggested that the quality of mechanical bowel preparation was closely related to
anastomotic dehiscence (Rosenberg et al, 1971). Irvin and
Goligher (1973), in their retrospective review of 204 handsutured large-bowel anastomoses, showed that the most
powerful determinant of anastomotic leakage was the
quality of mechanical bowel preparation. There were nine
leaks from 116 anastomoses when mechanical preparation was of good quality (8%), compared with 19 leaks
from 59 anastomoses when faecal residue was present at
the operation (32%). Morris et al (1983) reported anastomotic leaks or perianastomotic abscess in 1 of 76 patients
who had a good bowel preparation compared with 6 of 13
in those in whom there was gross faecal residue in the
colon. Similar observations have been made by others
(Schrock et al, 1973; Walls, 1980; Christensen and
Kronberg, 1981). Animal studies indicate that the bursting pressure at a colonic anastomosis is reduced if there is
increased faecal residue (Smith et al, 1983; ODwyer et al,
1989), possibly due to increased collagenase activity
(Hawley et al, 1970a,b; Ryan, 1970).
More recently, this issue has been addressed in the setting of randomised clinical trials. Miettinen et al (2000)
randomised 267 patients admitted for colorectal surgery to
either oral polyethylene glycol electrolyte solution (n = 138)
or no preparation (n = 129). Patients who were unable to
drink the polyethylene glycol electrolyte solution or who had
had bowel preparation in the previous week were excluded.
There were no differences in outcome between the two
groups: anastomotic leaks were 4% in the oral preparation

TABLE 3.13

group versus 2% in the no preparation group; other surgical site infections were 6% in the oral preparation group versus 5% in the no preparation group. Similarly, Ram et al
(2005) could find no advantage for mechanical bowel
preparation in a randomised controlled trial (RCT) of
patients undergoing elective colorectal surgery.
Zmora et al (2003a) recruited 415 patients into groups
for comparison of the effect of bowel preparation on postoperative sepsis: group A received 1 gallon of polyethylene
glycol 1216 hours before surgery (n = 187), group B
received no preoperative bowel cleansing (n = 193). The
groups were identical for demographics, indications for
surgery and type of surgery. After randomisation, 29
patients were excluded (18 APR, 11 proximal stoma).
Spillage of bowel content (Zmora et al, 2003b) was significantly more common in group A than group B. However,
there was no difference in the two groups in the rate
of postoperative wound infections, clinical anastomotic leaks
or intra-abdominal abscesses (Table 3.13). One patient in
each group died from sepsis related to an anastomotic
leak.
Slim et al (2004) conducted a meta-analysis of RCTs of
mechanical bowel preparation that identified 11 studies,
of which seven were felt to be suitable for inclusion. The
methodological quality of each trial was assessed for randomisation (Table 3.14), blinding and withdrawals or
dropouts; a trial was considered poor when it scored 2 or
less. The final meta-analysis for anastomotic leakage as the
outcome related to bowel preparation showed a negative
outcome for bowel preparation. Slim et al (2004) concluded that there was significantly higher incidence of
leaks in the preparation group than in the control group
(5.6% versus 3.2%; OR 1.74 (95% CI 1.05 to 2.90;
P = 0.032). They also concluded that wound infection was
higher after bowel preparation although not significantly
so (7.4% versus 5.7%; OR 1.33; 95% CI 0.882.03).
Bucher et al (2004), in a meta-analysis, examined seven
RCTs constituting 1297 patients undergoing elective colorectal surgery (642 who had received mechanical bowel
preparation and 655 who had not). Among all the RCTs
reviewed, anastomotic leak was significantly more frequent
in the mechanical bowel preparation group (35/642 =
5.6%), compared with the no mechanical bowel preparation group (18/655 = 2.8%) (OR 1.84; P = 0.03). By contrast, rates of intra-abdominal infection (3.7% for the
mechanical bowel preparation group versus 2.0% for the
no mechanical bowel preparation group), wound infection

RANDOMISED TRIAL OF PEG vs. NO PREPARATION

Anastomotic leak
Intra-abdominal abscess
Wound infection
Total
After Zmora et al (2003a).
NS, not significant.

Group A: (n =187)
bowel
preparation
7 (3.7%)
2 (1.1%)
12 (5.4%)
19 (10.2%)

Group B: (n =193)
no bowel
preparation
4 (2.1%)
2 (1%)
11 (5.7%)
17 (8.8%)

P value
NS
NS
NS
NS

Risk Management

TABLE 3.14 META-ANALYSIS OF IMPACT OF BOWEL PREPARATION

ON ANASTOMOTIC LEAK RATES

Brownson et al, 1992

Santos et al, 1994
Burke et al, 1994
Miettinen et al, 2000
Fillman et al, 2001
Zmora et al, 2003a
Fa-Si-Oen 2003
Total

Quality
score
2
4
3
4
4
4
2

Leaks in prepared
patients
8/67
7/72
3/82
5/138
2/30
7/187
7/125
39/701

Leaks in
non-prepared patients
1/67
4/77
4/87
3/129
1/30
4/193
6/125
23/708

After Slim et al (2004).

(7.5% for the mechanical bowel preparation group versus

5.5% for the no mechanical bowel preparation group), and
reoperation (5.2% for the mechanical bowel preparation
group versus 2.2% for the no mechanical bowel preparation group) were not significantly different.
In the most recent Cochrane review (Guenaga et al,
2005; Wille-Jrgensen et al, 2005) of mechanical bowel
preparation in elective colorectal surgery, nine RCTs involving 1592 patients were identified. Of these, 789 were allocated to mechanical bowel preparation (group A) and 803
to no preparation (group B) before elective colorectal surgery. For anastomotic leakage (the main outcome) the
results were:

Low anterior resection: 9.8% (11 of 112 patients in group

A) compared with 7.5% (9 of 119 patients in group B);
Peto OR 1.45; 95% CI 0.573.67; not significant.
Colonic surgery: 2.9% (group A) compared with 1.6%
(group B); Peto OR 1.80; 95% CI 0.684.75; not significant.
Overall anastomotic leakage: 6.2% (group A) compared
with 3.2% (group B); Peto OR 2.03; 95% CI 1.2763.26;
P = 0.003).

For the secondary outcome of wound infection, the results

were: 7.4% (group A) compared with 5.4% (group B); Peto
OR 1.46, 95% CI 0.972.18; P = 0.07.
In our view, the place of mechanical bowel preparation as a technique to prevent anastomotic leakage and
postoperative wound sepsis must be called into doubt by
these findings. However, the widespread abandonment
of mechanical bowel preparation in all colorectal
resections should be viewed with some caution. The
definitive randomised study (assuming an infectious
complications rate of 10%), for a prospective study that
will be able to detect a difference of 5% in infection rate,
in a one-tailed statistical test, assuming an alpha level
of 0.05, with a statistical power of 90%, 770 patients
would be required to be randomised to each group
(Zmora et al, 2003b).
We would concur with Zmora and Habr-Gama (2004)
that mechanical bowel preparation still has a place in the
management of patients undergoing colorectal resection
especially low rectal cancer extirpation. Whereas this
probably does not apply to right hemicolectomy, we

would continue to advocate the use of mechanical bowel

preparation in the following two circumstances:

all patients in whom on table colonoscopy may form part

of the operative procedure
all patients in whom a distal anastomosis might require
a proximal defunctioning stoma.
all patients having an ultralow anterior resection.

COLORECTAL SURGERY AND SURGICAL

SITE INFECTIONS
Definition and surveillance
Wound infection or surgical site infection causes a substantial degree of illness and, in some cases, patient death
(Wilson et al, 2004). Hospital discharge is delayed and, as
a result, this complication alone produces a significant
increase in health-care costs: infected surgical wounds cost
the NHS over 62 million in 1995 (Plowman et al, 2001).
The definition of surgical site infection remains problematic. There are currently at least four common definitions in use (Wilson et al, 2004):

1992 Centers for Disease Control (CDC) definition: 16

wound or patient characteristics in the surgeons diagnosis of infection plus culture of microorganisms from
the wound.
US National Nosocomial Infections Surveillance System
(NINSS): as above but the NINSS criteria to be based on
positive cultures of tissue and fluid rather than wound
swabs.
English NINSS: modified CDC definition to exclude the
need for surgeons diagnosis and requires pus cells to be
present to satisfy the criterion of microorganisms cultured
from the wound.
ASEPSIS: quantitative scoring method that provides a
numerical score related to the severity of the wound infection using objective criteria based on wound appearance
and clinical consequences.

Wilson et al (2004) examined 5804 surgical wounds from

a variety of specialties and found that the mean percentage of wounds classified as infected differed substantially
with different definitions: 19.2% with the CDC definition
(95% CI 18.120.4%), 14.6% (13.615.6%) with the
NINSS version, 12.3% (11.413.2%) with pus alone and

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Chapter 3

Perioperative Care

6.8% (6.17.5%) with an ASEPSIS score > 20. In addition,

the agreement between definitions with respect to individual wounds was poor. Thus, whereas a single definition of
surgical site infection used consistently can show changes
in wound infection rates over time at a single centre,
differences in interpretation may prevent comparison
between centres. Similarly, Bruce et al (2001) using a systematic review of prospective studies of surgical wound
infection published over a 7-year period (19939), identified extensive variation in the definition of surgical wound
infection used in clinical practice.
In the UK, the Department of Health and the Public
Health Laboratory Service have established a NINSS in
England. Hospitals are required to collect data over a minimum of 3 months, data collection being coordinated by
the Infection Control Team in each hospital (Wilson et al,
2002). Infection Control Teams have shown considerable
support for this approach, with results being passed back
to clinicians and managers. As a result, two-thirds of hospitals have reviewed or changed clinical practice (Wilson
et al, 2002). The responsibility for conducting this exercise
is now with the Health Protection Agency, which has
defined the categories for surgical site infection surveillance.
For large bowel surgery these are: incision, excision or anastomosis of the large bowel including procedures that involve
anastomosis of the small to large bowel. The definitions of
surgical site infection are given in (Table 3.15).
A NNIS risk index has been developed to stratify the risk
of surgical site infection, each operation being scored by
the presence or absence of three risk factors at the time of
surgery:

ASA of > 2.
Operation classified as contaminated or dirty.
An operation lasting for a specific period of time (T hours)
where T is the 75th percentile of the duration of surgery
and depends on the surgical procedure being performed
(for large bowel surgery, T = 3 hours).

Each of the risk factors contributes one point to the risk

index, which therefore ranges from 0 to 3 (if all risk factors
present) (Health Protection Agency, 2004).
Table 3.16 shows the the distribution of surgical site
infection rates and risk index category in the American
National Nosocomial Infections Surveillance (NNIS)
System Report (2003).

Surgical site infection prophylaxis

Operating room routine
Quite apart from surgical technique, operating theatre discipline is believed by many to reduce the risk of contamination, and consequently the incidence of sepsis (Hughes,
1972; Krukowski et al, 1984). In the UK and USA, povidineiodine and chlorhexidine gluconate are the scrub
agents of choice for the surgical team (Mangram et al,
1999). No clinical trials have evaluated the impact of the
scrub agent on surgical site infections. The first scrub of
the day should include a thorough cleaning underneath
the fingernails usually with a brush. A 2-minute scrub may
be as effective as a 10-minute scrub in reducing bacterial
colony counts but the optimum duration is not known
(Mangram et al, 1999). Parienti et al (2002) compared two

hand-cleansing methods alternately every other month:

a hand-rubbing protocol with 75% aqueous alcoholic
solution containing propanol-1, propanol-2 and mecetronium etilsulfate, and a hand-scrubbing protocol with antiseptic preparation containing 4% povidoneiodine or 4%
chlorhexidine gluconate. Thirty-day surgical site infection
rates were 55 of 2252 (2.44%) in the hand-rubbing protocol and 53 of 2135 (2.48%) in the hand-scrubbing protocol, a difference of 0.04% (95% CI 0.880.96%). Thus
hand-rubbing with liquid aqueous alcoholic solution can
be safely used as an alternative to traditional surgical hand
scrubbing.
Wearing finger rings and nail polish was thought to
reduce the efficacy of the scrub as these are thought to
harbour bacteria (in microscopic imperfections of nail polish and on the skin beneath finger rings). However, in a
Cochrane review, no RCTs measured patient outcomes,
including surgical infection, with the wearing of finger
rings versus the removal of finger rings and there were no
trials of nail polish wearing versus removal (Arrowsmith
et al, 2001). In a further small RCT, nurses were allocated
to: unpolished nails, freshly applied nail polish (less than 2
days old), or old nail polish (more than 4 days old). Both
before and after surgical scrubbing, there was no significant difference in the number of bacteria on the hands.
However, the wearing of artificial nails has been associated
with isolated outbreaks of surgical site infection (Passaro
et al, 1997).
Although the use of barriers to separate the surgical
field from the live organisms shed by the surgical team
seems prudent, there are few controlled studies to support
the use of scrub suits and other covering attire (Mangram
et al, 1999). Clinical series demonstrate that the use of
tightly woven special scrub suits reduces the dispersal of
total counts of bacteria and of Staphylococcus aureus from
staff in the operating room, thus possibly reducing the risk
of airborne contamination of surgical wounds (Tammelin
et al, 2001). Surgical site infections have been linked to
organisms shed from the hair or scalp and therefore caps
and hoods reduce surgical field contamination (Mangram
et al, 1999). A recent Cochrane review of randomised studies of facemask versus non-facemask use concluded that it
remains unclear as to whether wearing a surgical face
mask results in any harm or benefit to the patient undergoing clean surgery (Lipp and Edwards, 2002). Shoe covers
or operating room restricted shoes transfer fewer bacteria
onto a disinfected floor area than do unprotected street
shoes (Copp et al, 1987). However, the use of shoe covers
has not been shown to decrease surgical site infections
(Mangram et al, 1999).
Sterile gloves have the dual role of stopping transmission of bacteria from the surgical team to the patient and
prevent contamination of the team members hands by the
patients blood and body fluids. Perforation of the latex
surgical glove negates this dual barrier and has led to the
practice of double gloving. A Cochrane systematic review
(Tanner and Parkinson, 2002) has concluded that wearing two pairs of latex gloves significantly reduces the number of perforations to the innermost glove. This evidence
comes from trials undertaken in low risk surgical specialties, i.e. specialties that do not include orthopaedic joint

Risk Management

TABLE 3.15

DEFINITION OF SURGICAL-SITE INFECTIONS

Superficial incisional infection

Definition
Surgical site infection that occurs within 30 days of surgery and involves only the skin or
subcutaneous tissue of the incision and meets at least one of the following criteria:
Criterion 1
Purulent drainage from the superficial incision
Criterion 2
The superficial incision yields organisms from the culture of aseptically aspirated fluid or tissue
or from a swab with pus cells present
Criterion 3
At least two of the following symptoms and signs
Pain or tenderness
Localised swelling
Redness
Heat and:
the superficial incision is deliberately opened by a surgeon to manage the infection, unless
incision culture is culture-negative
or:
the clinician diagnoses a superficial incisional infection
Important note
Stitch abscesses: these are defined as minimal inflammation and discharge confined to the
points of suture penetration and localised infection around a stab wound, They are not
classified as surgical site infections

Deep incisional infection

Definition
Surgical site infection involving the deep tissues (i.e. fascial and muscle layers) that occurs
within 30 days of surgery if no implant is in place or within a year if an implant is in place and
the infection appears to be related to the surgical procedure and meets at least one of the
following criteria:
Criterion 1
Purulent drainage from the deep incision but not from the organ/space component of the
surgical site
Criterion 2
The deep incision yields organisms from the culture of aseptically aspirated fluid or tissue or
from a swab with pus cells present
Criterion 3
A deep incision that spontaneously dehisces or is deliberately opened by a surgeon when the
patient has at least one of the following symptoms or signs:
Fever (> 38C)
Localised pain or tenderness
Unless the incision is culture negative
Criterion 4
An abscess or other evidence of infection involving the deep incision that is found by direct
examination during reoperation or by histopathological or radiological examination
Criterion 5
Diagnosis of a deep incisional surgical site infection by an attending clinician
Important note
An infection that involves both superficial and deep incision is classified as deep inicisonal
surgical site infection

Organ/space infection
Definition
Surgical site infection involving any part of the anatomy (i.e. organ/space) other than the
incision, opened or manipulated during the surgical procedure, that occurs within 30 days of
surgery if no implant is in place or within a year if an implant is in place and the infection
appears to be related to the surgical procedure and meets at least one of the following criteria:
Criterion 1
Purulent drainage from a drain that is placed through a stab wound into the organ/space
Criterion 2
The organ/space yields organisms from the culture of aseptically aspirated fluid or tissue or from
a swab with pus cells present
Criterion 3
An abscess or other evidence of infection involving the organ/space that is found by direct
examination during reoperation or by histopathological or radiological examination
Criterion 4
Diagnosis of an organ/space surgical site infection by an attending clinician
Important notes
1. Occasionally an organ/space infection drains through the incision. Such infection generally
does not require reoperation and is considered to be a complication of the incision and is
therefore classified as a deep incisional infection
2. Where doubt exists refer to the definitions of specific site of organ/space infection to
determine if the organ/space infection meets the definition
From Health Protection Agency (2004) http://www.hpa.org.uk/infections/topics_az/hai/menu.htm

91

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TABLE 3.16 DISTRIBUTION OF SURGICAL

SITE INFECTION RATES AND RISK INDEX
CATEGORY

Colon
Colon
Colon
Colon

Risk
index
category
0
1
2
3

Number
of
hospitals
94
102
81
27

Pooled
mean
rate
4.0%
5.64%
8.55%
11.53%

National Nosocomial Infections Surveillance (NNIS) System

Report (2003).

surgery. Wearing two pairs of latex gloves does not cause

the glove wearer to sustain more perforations to their outermost glove. Wearing double latex indicator gloves enables
the glove wearer to detect perforations to the outermost
glove more easily than when wearing double latex gloves
(Tanner and Parkinson, 2002). Furthermore, changing
surgical gloves before wound closure has been shown to be
associated with significantly fewer wound infections (2/46
= 5.5% gloves changed; 9/46 = 25% gloves not changed)
in a randomised comparison of women undergoing
caesarean section (Ventolini et al, 2004).

Skin preparation
Most colorectal surgeons accept the need for antiseptic
skin preparation as well as antibiotic prophylaxis as protection against bowel contamination during resection
(Ambrose et al, 1983a; McDonald et al, 1984). Skin preparation should be performed with two applications of an
alcohol-based preparation, which should be given adequate time to dry between applications (Lilly and Lowbury,
1971; Lowbury and Lilly, 1973; Lowbury et al, 1974).
Hexachlorophane may cause hypersensitivity reactions
(Cruse and Foord, 1973); chlorhexidine or iodine solutions
in an alcohol base are usually preferred. In a Cochrane
systematic review (Edwards et al, 2004), six eligible RCTs
evaluating preoperative antiseptics were identified.
Significant heterogeneity meant that comparisons and the
results could not be pooled. In one study, infection rates
were significantly lower when skin was prepared using
chlorhexidine compared with iodine. There was, however,
no evidence of a benefit in four trials associated with the
use of iodophor impregnated drapes. The current view is
that there is insufficient research examining the effects of
preoperative skin antiseptics to allow conclusions to be
drawn regarding their effects on postoperative surgical
wound infections (Edwards et al, 2004).

Surgical technique
Simple matters, such as ensuring that division of the bowel
is the last event in a colonic resection, and the use of
occluding tapes and staples reduce the duration and the
extent of contamination (Keighley et al, 1996). Ensuring
that an adequate sucker is available when the bowel
is divided and the use of large gauze swabs soaked in an
antiseptic solution helps to minimise contamination (Rietz

et al, 1984). Other simple measures include protecting the

end of the bowel prior to construction of a stoma with a
clamp or by staples to reduce contamination of the wound
and the stoma trephine. In addition the stoma should not
be constructed until the abdominal incision has been closed
and covered.
Gentleness in handling tissues, adequate perfusion of
the gut and avoidance of local ischaemia are important
surgical principles (Fawcett et al, 1996). Avoidance of tension at an anastomosis or a stoma and preserving an adequate blood supply to the colon are crucial. Other surgical
expedients, such as avoiding an anastomosis if there is
gross contamination or established infection, cannot be
overstressed (Fikri and McAdams, 1975; Hughes et al,
1982; Krukowski and Matheson, 1983; Ahrendt et al,
1994, 1996). Using these principles, Krukowski et al
(1984) reported an infection rate of only 1.8% in elective
colorectal surgery and a rate of 6.7% in emergency procedures. Synchronous surgical procedures increase the risk
of sepsis (Simchen et al, 1984).
Techniques to limit surgical site infections include the
use of drains after colorectal anastomosis to reduce or
prevent accumulation of fluids particularly blood in the
pelvic or peritoneal cavity and to permit early detection
of anastomotic dehiscence by faecal or purulent discharge
from the drain. However, Brown et al (2001) could not
show any difference in morbidity between patients that
did and those that did not receive a drain after infraperitoneal colorectal anastomosis. The French Association for
Surgical Research (Merad et al, 1999) conducted a large
randomised trial of 494 patients undergoing resection for
colorectal cancer, benign neoplasm, colonic Crohns disease and diverticular disease of the sigmoid colon followed
by colorectal anastomosis. Patients were randomised to
either drainage (n = 248) with two multiperforated 14F
suction drains or no drainage (n = 246). The incidence of
anastomotic leakage, postoperative reoperation and postoperative death were no different between the two groups.
In a Cochrane systematic review of surgical drains in
elective colorectal surgery (Jesus et al, 2004), of the 1140
patients enrolled (six RCTs), 573 were allocated for
drainage and 567 for no drainage. The patients in the two
groups had very similar outcomes in terms of postoperative complications and deaths (Table 3.17). Others
(Urbach et al, 1999; Petrowsky et al, 2004)using
largely the same RCT evidence in a meta-analysishave
similarly concluded that routine prophylactic drainage
provides no benefit after uncomplicated major colon and
rectal surgeries.
At the conclusion of the procedure and before stoma formation, a wound dressing is used to cover the closed incision for 2448 hours (Mangram et al, 1999). The evidence
as to which type of wound dressing best prevents surgical
site infection is very limited. Holm et al (1998), in a very
small study of clean wounds, found no difference in infection rates when two dressing techniquesMepore and
Comfeelwere compared. Burrows (2000) included this
latter study and two others in an attempt to answer the
question as to whether occlusive or non-occlusive dressings best reduced infections in surgical wounds. From the
results of three trials analysed, it was concluded that the

Risk Management

TABLE 3.17 RANDOMIZED TRIAL OF

DRAINS IN COLORECTAL SURGERY
Mortality
Clinical anastomotic
dehiscence
Radiological
anastomotic
dehiscence
Wound infection
Re-intervention
Extra abdominal
complications

Drainage
18/573 (3%)
11/522 (2%)

Non-drainage
25/567(4%)
7/519 (1%)

16/522 (3%)

19/519 (4%)

29/573 (5%)
24/542 (6%)
34/522 (7%)

28/567 (5%)
28/539 (5%)
32/519 (6%)

After Jesus et al (2004).

use of occlusive dressings was not associated with a reduction in wound infection rates but that larger trials were
probably required if a significant difference was to be
detected. Similarly, the need for wound dressing after 48
hours has not been supported by a reduced infection rate
in a comparison of two groups of 50 patients each (Meylan
and Tschantz, 2001).

Intraoperative antiseptics
Antiseptics can damage small blood vessels, collagen synthesis and rapidly dividing cells (Brennan et al, 1986).
Kuijpers (1985) questioned the wisdom of using povidoneiodine in patients with peritonitis, because this can
cause serious peritoneal damage. However, it can be useful
if there has been inadvertent faecal contamination
(Browne and Stoller, 1970; Gilmore et al, 1978b;
Ahrenholz and Simmons, 1979; Flint et al, 1979; Sindelar
and Mason, 1979). Most authorities believe that antiseptic lavage is unsafe if there is established inflammation, as
in faecal or purulent peritonitis (Lagarde et al, 1978;
McAvinchey et al, 1983). Neither continuous saline
nor antiseptic lavage influenced postoperative sepsis
in colorectal surgery (Hallerback and Andersson, 1986;
Leiboff and Soroff, 1987; Baker et al, 1994).
Intraluminal antiseptics may be used for rectal washouts
as they reduce the counts of luminal bacteria (Jones et al,
1976; Scammell et al, 1985). Povidoneiodine rectal
washout can be extended in a retrograde fashion to the
whole colon: 1 L reaches the caecum in 2 minutes (Mariani
et al, 2002). Although the use of povidoneiodine in this
fashion is associated with increased systemic iodine absorption, it appears that a single intraoperative bowel irrigation
with povidoneiodine may be performed with practically
no risk (Tsunoda et al, 2000).
Antiseptics have been applied to the wound at the end
of the operation to minimise the consequences of inadvertent contamination (Gilmore and Sanderson, 1975;
Gilmore, 1977; Stokes et al, 1977; Gilmore et al, 1978a;
Sindelar and Mason, 1979; Galle and Homersley, 1980; de
Jong et al, 1982). A more recent extension of this approach
has been the development of antiseptic wound ventilation
with a combination of CO2 and 95% ethanol (Persson et al,
2003). On filter disks, CO2 carrying vapour from a 95%

ethanol solution decreased the number of colony-forming

units after 5 min of exposure (P = 0.04), and killed all
bacteria within 1015 min (P < 0.001).

Optimising the wound environment

The wound environment is increasingly recognised as having a key role in determining its susceptibility to surgical
site infection. Obesity is associated with an increased incidence of wound-site infection. Tsukada et al (2004) calculated the intra-abdominal fat area (IAF) and the
subcutaneous fat area (SCF) for 139 patients undergoing
elective gastric or colorectal cancer surgery using a CT scan
of the abdomen performed at the level of the umbilicus.
The IAF area was quantified by delineating the border of
the peritoneal cavity and was computed as the area with
an attenuation range of 250 to 50 Hounsfield units. The
abdominal SCF area was calculated by subtracting the visceral fat area from the total abdominal fat area. Using the
criteria of Japan Society for Study of Obesity, the IAF cutoff point was 160 cm2 for males and 120 cm2 for females,
and SCF cut off point was 180 cm2 for males and 250 cm2
for females. Nineteen patients (Tsukada et al, 2004) had
surgery-related complications (anastomotic leakage, intraabdominal collections or abdominal wound infection) and
these were significantly associated with IAF and SCF values greater than the cut-off points. Kabon et al (2004) has
subsequently demonstrated that intraoperative subcutaneous tissue oxygen tension is significantly less in obese
patients (BMI > 30 kg/m2) at baseline (36 versus 57
mmHg; P = 0.002) and with supplemental oxygen administration (47 versus 76 mmHg; P = 0.014). Immediate
postoperative tissue oxygen tension is also significantly less
in subcutaneous tissue of the upper arm (43 versus 54
mmHg; P = 0.011) as well as near the incision (42 versus
62 mmHg; P = 0.012) in obese patients.
Melling et al (2001) conducted a randomised study of
wound warming. 421 patients having clean (breast, varicose vein, or hernia) incisions closed after surgery. Patients
randomly assigned to the non-warmed (standard) group
received the usual preoperative care, without any active
temperature control. Patients in the systemic warming
group received the same standard preoperative care, plus
the addition of a minimum 30-minute preoperative warming to the whole body using a forced-air, warming blanket.
Patients assigned to the local warming group also received
the standard care and a minimum 30-minute preoperative
warming to just the planned wound area using a non-contact, radiant heat dressing. Both warming devices were left
in situ until just before surgery. A wound was classified as
infected if there had been a purulent discharge or a painful
erythema that lasted for 5 days and was treated with
antibiotics within 6 weeks of surgery. Warming (local
and/or systemic) was associated with significantly reduced
postoperative wound infection rate (Table 3.18).
Interestingly, local radiant heating has been shown to
increase subcutaneous oxygen tension for several hours
after the heating has been discontinued (Ikeda et al, 1998)
and wound oxygenation has also been identified as a significant factor in avoiding wound infection in patients
undergoing colorectal resection (Gottrup, 2004). Hopf et al
(1997) identified the subcutaneous oxygen tension as a

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patients means that, in clinical practice, oxygen should

continue to be administered with the goals of maintaining
adequate haemoglobin oxygen saturation and ensuring
adequate oxygen transport, rather than achieving supranormal levels of arterial oxygen tension.

TABLE 3.18 IMPACT OF WARMING ON

WOUND INFECTIONS

Local warming
Systemic warming
All warmed patients
Non-warmed
P

n
138
139
277
139

Wound
infection rate
5 (4%)
8 (6%)
13 (5%)
19 (14%)
0.001

Perioperative antibiotic prophylaxis

The term prophylaxis should be confined to colorectal
surgery undertaken in the absence of established sepsis
(Wittmann and Schein, 1996). Hence, antibiotic cover for
disease complicated by pericolic abscess, a fistula or active
perianal disease cannot be classified as prophylaxis and the
term therapy should be used.

After Melling et al (2001).

stronger predictor of wound infection than the SENIC

(Study on the Efficacy of Nosocomial Infection Control)
score. A randomised study of 500 patients undergoing colorectal operations (Greif et al, 2000) compared the effects
of two supplemental oxygen regimens (Table 3.19) on the
development of postoperative wound infection30% oxygen during and 2 hours after surgery versus 80% oxygen
during and 2 hours after surgery. The 80% oxygen supplemental group had a much lower incidence of wound
infection.
More recently, however, the routine use of perioperative
hyperoxia in reducing surgical-site infection has been
challenged. Pryor et al (2004) randomly assigned general
surgical patients to receive either 80% oxygen (FiO2 of
0.80) or 35% oxygen (FiO2 of 0.35) during surgery and for
the first 2 hours after surgery. The overall incidence of surgical-site infection was 18.1%: patients who developed surgical-site infection having a significantly longer period of
hospitalisation after surgery (mean [S.D.] 13.3 [9.9] versus 6.0 [4.2] days; P < 0.001). In contrast to previous studies, however, the incidence of infection was significantly
higher in the group receiving FiO2 of 0.80 than in the
group with FiO2 of 0.35 (25.0% versus 11.3%; P = 0.02).
Indeed, in this study FiO2 was a significant predictor of surgical-site infection (P = 0.03) in multivariate regression
analysis (Pryor et al, 2004). Aspects of this latter study,
such as identifying wound infection from retrospective
chart review (Akca and Sessler, 2004; Hopf et al, 2004)
and aspects of randomisation (Greif and Sessler, 2004)
have attracted criticism. Other commentators (Urbach,
2004) take the view that the possibility of an adverse effect
of high FiO2 on surgical site infection in some surgical

Topical antibiotics
Topical antibiotics have been explored but administration
is rarely advised in colorectal procedures (Nash and Hugh,
1967; Anderson et al, 1972; Evans and Pollock, 1973;
Stone and Hester, 1973; Evans et al, 1974; Holder, 1976;
Lord et al, 1977; Greenhall et al, 1979; Brumfitt and
Hamilton-Miller, 1980; Pitt et al, 1980; Pollock, 1981). In
intestinal surgery, topical cephradine was inferior to systemic antibiotic administration (Finch et al, 1979). The
combination of broad-spectrum systemic antibiotic cover
and topical agents conferred no benefit over intravenous
administration alone in colorectal surgery (Moesgaard
et al, 1988; Raahave et al, 1989). A recent meta-analysis
indicates that topical ampicillin versus no antibiotic prophylaxis in both clean contaminated wounds and contaminated wounds significantly reduces surgical wound
infection rates (clean contaminated wounds OR = 0.084;
95% CI 0.040.16; P < 0.0001; contaminated wounds
OR = 0.262; 95% CI 0.140.51; P < 0.0001). However,
topical ampicillin combined with systemic antibiotics
offers no reduction in surgical wound infection rates
over systemic antibiotics alone (Charalambous et al, 2003).
A recent Health Technology Assessment of antimicrobial
prophylaxis in colorectal surgery could find no additional
benefit in six trials that compared parenteral alone with
parenteral plus topical wound antibiotic prophylaxis
(Song and Glenny, 1998).
Intraincisional antibiotics
Antibiotics may be administered by injection into the subcutaneous tissues and the rectus muscle immediately prior
to laparotomy (Armstrong et al, 1982; Taylor et al, 1982;

TABLE 3.19 EFFECTS OF TWO SUPPLEMENTAL OXYGEN REGIMENS

ON THE DEVELOPMENT OF POSTOPERATIVE WOUND INFECTION

Wound infection
ASEPSIS score
Solid food (days)
Skin staples out (days)
Length of stay (days)
From Greif et al (2000).
NS, not significant.

30% oxygen
(n = 250)
28 (11.2%)
59
4.4
10.4
11.9

80% oxygen
(n = 250)
13 (5.2%)
37
4.5
10.3
12.2

P
0.01
0.01
NS
NS
NS

Risk Management

Chalkiadakis et al, 1995). This method of delivery is

associated with more sustained serum levels of antibiotic
than if the same agent is given intravenously. Clinical trials
indicate that this method of antibiotic cover may be
comparable to systemic antibiotic cover in prevention of
wound sepsis in large-bowel surgery (Pollock et al, 1989).
Infusion of kanamycin into the wound, allowing it to dwell
for 2 hours, was associated with a very low wound infection rate in 400 morbidly obese patients undergoing open
gastric bypass (Alexander and Rahn, 2004).
Antibiotic peritoneal lavage
Antibiotic peritoneal lavage is controversial in colorectal
practice both for prophylaxis and treatment of intra-abdominal sepsis (Krukowski and Matheson, 1983; Krukowski
et al, 1984). Lavage with saline alone may be dangerous
because microorganisms may be disseminated by peritoneal
lavage (Minervini et al, 1980b; Ambrose et al, 1982).
Antibiotic lavage may be dangerous in faecal or purulent
peritonitis because absorption is much more rapid and toxic
serum levels have been reported (Ericsson et al, 1978).
Renal failure and adhesive obstruction may occur if tetracycline lavage is used in acute peritonitis (Sandle and
Mandell, 1980; Phillips and Dudley, 1984).
Washington et al (1974) reported a significantly reduced
rate of residual abdominal sepsis with erythromycin lavage
compared with saline alone in diffuse bacterial peritonitis.
Williams and Champion (2004) demonstrated significant
bacterial contamination of the peritoneal cavity adjacent
to a laparoscopic entero-enterostomy but no clinical infections after the use of parenteral antibiotics and peritoneal
antibiotic lavage.
Stephen and Loewenthal (1979) claimed that peritoneal
lavage with gentamicin, cephalothin and lincomycin
improved survival and reduced the risk of residual abscess.
Others maintain that lavage with a broad-spectrum antibiotic is effective (Rambo, 1972; Moukhtar and Romney,
1980; Jennings et al, 1982). Tetracycline lavage is reported
by some to reduce sepsis in peritonitis from appendicitis and
in colorectal surgery because of the very high peritoneal
concentrations of tetracycline achieved in this way.
However, these studies were not randomised (Steigbigel
et al, 1968; Stewart and Matheson, 1978; Krukowski et al,
1984). In a randomised trial of tetracycline lavage in contaminated colorectal surgery, wound infection rates were

reduced but there was no influence on intra-abdominal

sepsis despite a sustained reduction in the counts of aerobic and anaerobic organisms in the peritoneal cavity
(Silverman et al, 1986). However, more recently tetracycline has been withdrawn, and has been replaced in some
centres by other antibiotic peritoneal lavage solutions such
as cefotaxime (1 mg/mL) (Jansen et al, 2002).
As most antibiotics administered systemically achieve
high concentrations in peritoneal fluid, the intravenous
route is generally preferred for antibiotic administration
in the treatment of established intra-abdominal sepsis
(Schiessel et al, 1984). Furthermore, Sauven et al (1986)
reported that short-term antibiotic cover was superior to
tetracycline lavage. Similarly, Pearl and Rayburn (2004)
concluded that minimal peritoneal lavage with nonantibiotic containing solutions is adequate in wound
prophylaxis.

Oral antimicrobial agents

Antimicrobial prophylaxis in elective colorectal surgery
used to be exclusively by oral agents, such as neomycin or
the sulphonamides, which although poorly absorbed are
thought to be capable of reducing the faecal flora. However,
none was clinically effective because they had no influence
on the gut anaerobes (Poth and Knotts, 1942; Everett et al,
1969; Washington et al, 1974; Varquish et al, 1978;
Taylor et al, 1979).
Neomycin with metronidazole, however, caused a profound fall in the counts of aerobic and anaerobic flora in
the colon (Arabi et al, 1978), with a significant reduction
in postoperative sepsis (Matheson et al, 1978). Neomycin
and erythromycin base also reduced the counts of streptococci, coliforms and Bacteroides spp. and clinical studies
indicated that these agents were capable of achieving a significant reduction in the rates of infection in elective colorectal surgery (Nichols et al, 1971, 1972; Clarke et al,
1977; Bartlett et al, 1978). Stenosing tumours of the large
bowel did not adversely effect the reduction in faecal
microflora achieved by oral antimicrobial agents (Figure
3.7). A significant reduction in faecal flora and postoperative sepsis was observed using kanamycin and metronidazole (Goldring et al, 1975; Keighley et al, 1979). However,
metronidazole alone had no influence on the faecal flora
unless there was severe diarrhoea (Lewis et al, 1977; Arabi
et al, 1978).

Figure 3.7 Profile of serum

gentamicin concentration against
time. Cinc, incision concentration; Cclos
closure concentration. After Zelenitsky
et al (2002).

Concentration (mg/L)

25
Cinc

20
15

Cclos

10
AUClurg

5
0
0

Time (hours)

95

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Chapter 3

Perioperative Care

In a prospective multicentre randomised controlled

study involving 11 centres, Clarke et al (1977) reported
that oral neomycin and erythromycin reduced sepsis from
43% to 9% but 407 patients were excluded, leaving only
116 for eventual analysis. Brass et al (1978) found that the
combination of neomycin and erythromycin was inferior
to neomycin with metronidazole. Varquish et al (1978)
showed that neomycin and erythromycin was no better
than neomycin alone. If antibiotics are to be used to reduce
gut flora, ciprofloxacin may be more effective because it is
rapidly absorbed (Taylor and Lindsay, 1994; McArdle et al,
1995).
When Weaver et al (1986) compared oral erythromycin and neomycin with systemic antibiotic cover the study
had to be discontinued after the entry of only 60 patients
because of a 48% sepsis rate with the oral regimen. A systematic review of RCTs of antimicrobial prophylaxis in colorectal surgery concluded that trials that showed extra
benefit from the use of oral antibiotics used inadequate parenteral regimens for comparison (Song and Glenny, 1998).
Other serious disadvantages of oral agents are the promotion of antibiotic resistance (Hartley and Richmond, 1975;
Keighley and Burdon, 1979; Lacey, 1980), superinfection
from yeasts or staphylococci and the risk of antibioticassociated colitis (Keighley et al, 1979).
The combination of neomycin with erythromycin still
has a considerable impact in parts of North America
(Nichols et al, 1997; Nichols, 2001). The common practice among colorectal surgeons in the USA uses both intraluminal and parenteral prophylaxis, with the parenteral
medication administered immediately before the operation
(Handelsman et al, 1993; Woods and Dellinger, 1998).
A total of 471 of 808 board-certified colorectal surgeons
responded to a survey of their current bowel preparation
practices before elective procedures. Most (86.5%) include
oral and parenteral antibiotics in their regimen; 11.5%
used only parenteral antibiotics, 1.1% used only oral
antibiotics and 0.9% used no antibiotics (Nichols
et al, 1997). The American Society of Health-System
Pharmacists (ASHP) therapeutic guidelines include
in their recommendations for colorectal surgery oral
neomycin sulphate 1 g and erythromycin base 1 g given
after bowel preparation is complete at 19, 18, and 9 hours
before surgery. The guidelines add that if the oral route is
contraindicated then a single 2-g dose of an intravenous
cephalosporin with both aerobic and anaerobic activity
should be administered at induction of anaesthesia (ASHP,
1999).
There is, however, some evidence that this practice
might change. Zmora et al (2003b) obtained 515 responses
(81% colorectal accredited, average time in practice 13.7
years) from 1295 questionnaires. Half of the respondents
stated that prophylactic oral antibiotics were essential, 41%
felt their place was doubtful and 10% considered oral prophylaxis unnecessary. Despite these views, 75% of the surgeons routinely utilised oral antibiotics (96% of them used
a combination of two drugs), 11% used them selectively
and only 13% omitted oral prophylaxis from their practice.
Similarly, although the usefulness of intravenous antibiotics
was questioned by 11% of the surgeons, 98% used them
routinely (Zmora et al, 2003b).

Systemic antimicrobial prophylaxis

Early studies compared antibiotic prophylaxis with no
antibiotic cover at all and, almost without exception, these
indicated that some form of prophylaxis is better than
no cover at all (Stokes et al, 1974; Griffiths et al, 1976;
Keighley and Crapp, 1976; Keighley et al, 1976; Downing
et al, 1977; Willis et al, 1977; Hojer and Wetterfors, 1978;
Eykyn et al, 1979). Two principles are important to follow
when selecting an antibiotic prophylactic regimen in
colorectal surgery (Song and Glenny, 1998):

The selected antibiotic(s) should be active against aerobic

and anaerobic bacteria.
The administration of antibiotics should be timed to
ensure that tissue concentration within the wound is high
when bacterial contamination occurs.

Principles of systemic antibiotic prophylaxis

Timing of antibiotic administration

Antibiotics are only effective when given immediately prior

to the inoculation of bacteria into wounds (Burke, 1961).
These principles were confirmed clinically by Stone and his
colleagues (1976), who showed that if antibiotic administration was delayed for 14 hours after operation, the rate
of sepsis was the same as if no antibiotic cover had been
given at all. Systemic antibiotics should be administered
immediately before the start of an operation, either in the
anaesthetic room or in the theatre (Bates et al, 1989).
Zelenitsky et al (2002) studied wound infection rates in
colorectal surgical patients receiving gentamicin prophylaxis. The gentamicin concentration at the time of surgical
closure was one of the strongest independent risk factors
for infection (P = 0.02), along with the presence of diabetes mellitus (P = 0.02), stoma (P = 0.04), and advanced
age (P = 0.05). Gentamicin concentrations at closure of
< 0.5 mg/L were associated with an infection rate of 80%
(representing 8/10 patients with concentrations below that
level; P = 0.003). ROC curve analysis identified a critical
closure concentration of 1.6 mg/L for effective surgical
prophylaxis (P = 0.002; sensitivity, 70.8%; specificity,
65.9%) (see Figure 3.7).
Timing of prophylaxis still requires emphasis. Bratzler
et al (2005) carried out a retrospective cohort study of
34 133 Medicare inpatients undergoing a range of procedures, including colorectal resection, to determine the
timing of antibiotic prophylaxis in relation to the timing
of the incision. In this large study only 55.7% (95% CI
54.856.6%) of patients received their antimicrobial prophylaxis within 1 hour before incision. Galandiuk et al
(2004) found that hospital participation in a quality network improved the rate of timely antibiotic administration in patients undergoing both colon and rectal
resections. In the first 30 months of the study period for
colon resection, 66% of patients (63/96) received a systemic antibiotic preoperatively compared with 98%
(117/119) in the second half of the study period (P <
0.0001). Similarly, for rectal resections, in the first half
of the study period, 79% of patients (34/43) received
antibiotic preoperatively compared with 100% of patients
in the last 30-plus months of the study period (P <
0.0001).

Risk Management

Route of administration: oral or systemic?

A few studies have compared oral against systemic antimicrobial prophylaxis. In three, oral administration was
inferior to systemic antibiotic cover (Keighley et al, 1979;
Weaver et al, 1986; Lau et al, 1988), whereas two studies
showed no difference (Aeberhard et al, 1979; Beggs et al,
1982). The combination of oral and systemic antibiotic
cover was shown to be superior to intravenous administration alone in three studies (Kaiser et al, 1983; Playforth
et al, 1988; Taylor and Lindsay, 1994), equivalent in one
study (Lau et al, 1988) and inferior in another (Coppa and
Eng, 1988).
Espin-Basany et al (2005) compared 300 elective
patients undergoing colorectal resection randomised to one
of the following three groups: group A received three doses
of oral antibiotic at the time of mechanical colon cleansing (1 g neomycin and 1 g metronidazole at 3.00 p.m.,
7.00 p.m. and 11.00 p.m.); group B received one dose of
oral antibiotic (1 g neomycin and 1 g metronidazole at
3.00 p.m.) and group C received no oral antibiotics. Not
only did oral antibiotics not confer any advantage in reducing wound sepsis (Table 3.20), but patient tolerance to oral
antibiotics, reflected as gastrointestinal symptoms at the
time of preoperative preparation for surgery (i.e. nausea,
vomiting), was significantly more common in patients with
combined treatment (group A) than in those who did not
receive oral antibiotics or received only one dose.
Influence on faecal flora

In view of the dangers of disturbing the normal faecal

flora, it is appropriate to consider the influence of intravenous antibiotic administration on colonic microflora.
Jonkers et al (2002) studied cardiac surgery patients who
received cefazolin as antibiotic prophylaxis (2 g intravenously just before surgery and then 1 g intravenously
every 6 hours for 18 hours). Patients who were receiving
therapeutic antibiotics during hospitalisation were
excluded. Discharged patients had received 24-hour cefazolin prophylaxis and had a mean hospital stay of 10 5
days. The prevalence of resistance of Escherichia coli to
amoxicillin (P < 0.05), cefazolin (P < 0.05) and oxytetracycline was higher for patients at discharge (41%, 12% and
35%) than for patients at admission (28%, 2% and 27%).
Intravenous doxycycline and many of the third-generation

cephalosporins suppress faecal microflora with the emergence of Clostridium difficile (Ambrose et al, 1985), whereas
tinidazole, metronidazole and most of the penicillins
have little, if any, influence (Heimdahl and Nord, 1979;
Heimdahl et al, 1982; Kager et al, 1985).
Prophylactic regimens

The antibiotics chosen for prophylaxis should provide adequate serum concentrations for the duration of the operation. Some cephalosporins, penicillins and aminoglycosides
have extremely short half-lives. Therefore, for complex
colorectal procedures involving excessive blood loss or prolonged operation, repeated intraoperative antibiotic administration may be indicated (Burdon et al, 1985).
With the exception of a study with four major variables
and small numbers (McArdle et al, 1995) most now indicate that, provided antibiotics with an adequate half-life
are used for prophylaxis, single-dose cover is as effective as
prolonged antibiotic cover for 24 hours or even several days
(Higgens et al, 1980; Giercksky et al, 1982; Goransson
et al, 1984; Dipiro et al, 1986; Juul et al, 1987; Jensen et al,
1990; Rowe-Jones et al, 1990; Wittmann and Schein,
1996). Agents such as ceftriaxone, with a long serum halflife, have been particularly effective in large-bowel surgery
(Shepherd et al, 1986; Weaver et al, 1986; Morris, 1993;
Matikainen and Hiltunen, 1993). Song and Glenny (1998)
in a health technology assessment, examined seventeen
randomised trials comparing a single-dose regimen with a
multiple-dose regimen (one or two doses) using the same
antibiotic or combinations of antibiotics. None of these trials found a significant difference in postoperative surgical
wound infection between single dose and multiple dose
regimens.
Many studies have examined single and combined
antibiotic agent efficacy for prophylaxis in colorectal surgery (Morris et al, 1984; Cunliffe et al, 1985; Norwegian
Study Group, 1985; Roland et al, 1986; Bergman and
Solhaug, 1987). So far, single-agent, broad-spectrum
antibiotic cover does not seem to be sufficiently reliable
to be advised in colorectal surgery (Hares et al, 1981a;
de la Hunt and Karran, 1986; McCulloch et al, 1986; Tudor
et al, 1988; Walker et al, 1988; Hall et al, 1989;
Kingston et al, 1989; Taylor and Lindsay, 1994). A specific anaerobicide alone is inadequate for prophylaxis

TABLE 3.20 COMPARISON OF POSTOPERATIVE COMPLICATIONS

AMONG TREATMENT GROUPS
Wound infection
Suture dehiscence
Postoperative ileus
Urinary tract infection
Intra-abdominal abscess
Pneumonia

Group A %
7
2
7
4
4
0

Group B %
8
2
13
4
3
1

Group C %
6
3
10
3
4
2

P value
0.858
0.368

After Espin-Basany et al (2005).

Group A: three doses of oral antibiotic at the time of mechanical colon cleansing (1 g of neomycin
and 1 g of metronidazole at 3.00 p.m., 7.00 p.m. and 11.00 p.m.); group B: one dose of oral antibiotic
(1 g of neomycin and 1 g of metronidazole at 3:00 p.m.); group C: no oral antibiotics.

97

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Chapter 3

Perioperative Care

(Cunliffe et al, 1985; Roland et al, 1986; Khubchandani

et al, 1989). Cephalosporins or penicillins in combination with a -lactamase inhibitor are less effective than
their use in combination with metronidazole because
they are not sufficiently active in vivo against faecal
anaerobes (Condon et al, 1979; Hoffmann et al, 1981;
Kager et al, 1981; Ivarsson et al, 1982; Kaiser et al,
1983; Peck et al, 1984; Baker et al, 1985; Drumm and
Donovan, 1985; de la Hunt and Karran, 1986; Hall et al,
1989; Hakansson et al, 1993). Song and Glenny (1998)
analysed a total of 147 RCTs exploring antibiotic prophylaxis in colorectal surgery. They concluded that the
estimates of efficacy of many of the different regimens
were very similar. As a result it was not possible to identify a best one. However, they found that there was no
convincing evidence that new generation cephalosporins
are more efficacious than first generation cephalosporins
in preventing surgical wound infection in colorectal
surgery.
Platell and Hall (2001) note that, given the results of
numerous previous trials, it would appear that clinical
trials of antibiotic wound prophylaxis in colorectal surgery
are being performed with the commercial intent of establishing equivalence. It is therefore pertinent that Woodfield
et al (2005) carried out a prospective randomised comparison of the pharmacoeconomic effectiveness of ceftriaxone and cefotaxime prophylaxis in abdominal surgery,
the aim being to use the cost of infection as a direct measurement of the severity of infection. In this study, 1013
patients admitted into a general surgical unit for both
acute and arranged abdominal surgery were studied over
a 3-year period. The major endpoint was superficial or deep
surgical site infection. Hospital costs associated with wound
infection along with outpatient costs (outpatient clinics,
accident and emergency care, the use of community nursing service, loss of wages, the use of primary care and
private health-care services, insurance expenses, and supplements to income by social welfare) were ascertained.
The frequency (Woodfield et al, 2005) of wound infection for appendicectomies when additional metronidazole
was not administered was greater with cefotaxime (ceftri-

axone 6%, cefotaxime 18%, P < 0.05) but the cost of infection was the same (average cost ceftriaxone $994 s.d.
$1101, cefotaxime $878 $1318). For all other procedures, the frequency of wound infection was similar (ceftriaxone 8%, cefotaxime 10%) but the cost was less with
ceftriaxone (ceftriaxone $887 $1743, cefotaxime $2995
$6592; P < 0.05). Ceftriaxone decreased the frequency
but not the cost of chest and urinary infection (frequency ceftriaxone 6%, cefotaxime 11%; P < 0.02; cost ceftriaxone $1273 2338, cefotaxime $1615 4083).
Ceftriaxone decreased either the frequency or the cost of
different postoperative infections (Table 3.21). In the
future, the cost of infection after antibiotic prophylaxis may
both increase the discriminatory power of trials comparing
antibiotic effectiveness and provide a significant factor in
prophylactic regimen choice.
Methicillin-resistant Staphylococcus aureus
An unfortunate feature of all hospital medicine, including
colorectal surgical practice, is the increasing prevalence of
methicillin-resistant Staph. aureus (MRSA) (Figure 3.8),
which is now considered to be undergoing an epidemic
increase, hence the designation EMRSA for epidemic MRSA
strains (Leaper, 2004).
A retrospective cohort study at the Detroit Receiving
Hospital, between 1999 and 2001, of patients with Staph.
aureus bacteraemia compared outcomes associated with
MRSA isolates and methicillin-susceptible Staph. aureus
(MSSA; Lodise and McKinnon, 2005). Controlling for
confounding variables, patients with MRSA had a 1.5-fold
longer length of stay (19.1 versus 14.2 days; P = 0.005)
and a 2-fold increased cost of hospitalisation ($21 577 versus $11 668; P = 0.001) compared with MSSA. In addition, patients with MRSA were at increased risk of
infection-related death (Table 3.22).
Isolated strains of MRSA are numbered sequentially in
the UK, where three have dominated: EMRSA-1, which was
prevalent in the Thames regions in the 1980s and probably originating in Australia, and EMRSA-15 and EMRSA16, which are currently predominant in the UK and are
responsible for outbreaks elsewhere (Duckworth, 2003).

TABLE 3.21 COST OF SUPERFICIAL AND DEEP SURGICAL SITE

INFECTION
Ceftriaxone

Cefotaxime

All cases except appendectomy without metronidazole

Number of patients
379
358
Number with infection
31 (8%)
36 (10%)
Mean cost $ ( SD)
887 ( 1743)
2995 ( 6592)
Median cost $ (range)
170 (196767)
824 (2131 914)
Appendectomy without metronidazolezole
Number of patients
83
Number with infection
5 (6%)
Mean cost $ ( SD)
994 ( 1101)
Median cost $ (range)
614 (662860)
After Woodfield et al (2005).

100
18 (18%)
878 ( 1368)
330 (04557)

P value

NS
< 0.05*

< 0.05
NS

Risk Management

(destroy) (Wertheim et al, 2004). Although the evidence

base for formulating MRSA reduction programmes is complex, isolation of MRSA-positive individuals would appear
to play a central role (Cooper et al, 2004; Bissett, 2005).
44%

THROMBOEMBOLISM PROPHYLAXIS
Patients at risk
35%
34%
45%
42%

46%

49%
43%

41%

Figure 3.8 Methicillin-resistant isolates in Staphylococcus

aureus bacteraemia reports from England and Wales. From
http://www.hpa.org.uk/cdr/PDFfiles/2001/cdr0701.pdf

TABLE 3.22 UNIVARIATE ANALYSIS OF

THE IMPACT OF MRSA ON OUTCOMES
Outcome
Infection-related
mortality
LOS-SAB (days)
Cost-SAB ($)

MRSA
(n = 170)
52 (30.6 %)

MSSA
(n = 183) P value
28 (15.3%)
0.001

20.1
22 735

13.7
11 205

< 0.001
< 0.001

After Lodise and McKinnon (2005).

LOS, length of stay; SAB, Staphylococcus aureus bacteraemia.

Initial UK guidelines to reduce MRSA rates in UK hospitals

by a search and destroy policy were watered down by poor
support from senior management, lack of isolation facilities, high occupancy rates of beds and understaffing
(Duckworth, 2003). There is evidence that some of the
governments policies conflict with the prevention and control of infections. Seven out of 10 Hospital Trusts still have
bed occupancy rates levels that are higher than the 82%
target set by the Department of Health for 20034
(Kmietowicz, 2005).
The UK now has some of the highest rates of MRSA
infection in Europe (Duckworth, 2003). By contrast, the
prevalence of MRSA in the Netherlands is among the lowest in the world: the Netherlands prevalence of MRSA
among clinical Staph. aureus isolates < 1%. This success is
based on a search and destroy policy (Wertheim et al,
2004). All patients from countries outside the Netherlands
and contacts of MRSA patients are strictly isolated at hospital admission until screening cultures for MRSA prove
negative (search). In case of MRSA carriage, individuals
are kept in isolation and treated to eradicate MRSA

Although it is unlikely that minor anorectal surgery poses

a significant risk of venous thromboembolism, patients
undergoing major abdominal colorectal procedures are
at high risk of developing postoperative venous thromboembolism (The Standards Task Force of the American
Society of Colon and Rectal Surgeons, 2000). Estimates
from control groups of randomised prophylaxis trials show
that > 30% of colorectal surgical patients develop postoperative deep venous thrombosis (DVT) compared with
approximately 20% of all general surgery patients (McLeod
et al, 2001). Tongren (1983) found fatal pulmonary
embolism (PE) in 3.1% of colorectal surgery patients
and in 0.8% of those having other abdominal surgical
procedures.
Risk factors for venous thromboembolism include age
over 40 years, extended immobility or paralysis, prior
episodes of venous thromboembolism, malignancy, major
surgery, obesity, congestive heart failure, myocardial infarction, stroke, pelvic and long bone fractures, presence of an
indwelling femoral catheter, inflammatory bowel disease,
nephrotic syndrome and oestrogen use (Table 3.23) (Rosen
and Clagett, 1999). Among the hypercoagulable states that
contribute to the risk for venous thromboembolism are
activated protein C resistance (factor V R506Q [Leiden]
mutation), prothrombin 20210A, antithrombin III deficiency, and protein C and protein S deficiency, as well as
antiphospholipid antibodies, dysfibrinogenaemias, hyperhomocystinaemia, disorders of plasminogen and myeloproliferative disorders (Rosen and Clagett, 1999).
Because of the perceived risk of venous thromboembolism and the opportunity to reduce preventable postoperative deaths, there continues to be considerable interest

TABLE 3.23 RISK FACTORS FOR

THROMBOEMBOLISM
Major abdominal or pelvic surgery
Age > 40 years
Previous thromboembolic event
Hereditary hypercoagulable state
Malignancy
Morbid obesity
Inflammatory bowel disease
Stroke (with paralysis)
Prolonged immobilization
Heparin-induced thrombocytopenia
Congestive heart failure
Acute myocardial infarction
Oral contraceptives
Tamoxifen
Venous stasis
From Practice Parameters (2000).

99

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Chapter 3

Perioperative Care

in reducing postoperative mortality from this cause. Using

risk factors, prophylaxis against postoperative venous
thromboembolism should be tailored according to the
patients level of risk (Caprini et al, 1991). Two methods of
prophylaxis are available either separately or in combination: mechanical techniques (pneumatic compression
and/or graded compression stockings) or anticoagulant
prophylaxis.

Mechanical prophylaxis
Nicolaides et al (2001) reviewed the evidence for the efficacy of mechanical prophylaxis in patients undergoing
general surgical and urological procedures. When DVT was
assessed, by phlebography or fibrinogen uptake, a reduced
incidence of DVT was seen for both intermittent compression and the use of graduated elastic compression stockings. This review data from 13 studies of intermittent
pneumatic compression showed DVT formation in 7.7% of
776 patients compared with 24% of 835 control patients.
A pooled comparison for the prophylactic use of graduated
compression stockings demonstrated a DVT rate of 11% in
463 patients subjected to the intervention compared with
29% of the 446 control patients (Nicolaides et al, 2001).
In a Cochrane systematic review, Amaragiri and Lees
(2000) considered the outcomes of seven RCTs in which
graduated compression stockings were the sole form of prophylaxis in a treatment group of 536 patients. The use of
compression stockings was associated with a DVT rate of
15% (assessed by I125 uptake test) compared with 29% in the
491 control patients (Petos OR 0.36; 95% CI 0.260.49)
with an overall effect of favouring treatment with graduated
compression stockings (P < 0.00001). The authors also concluded that graduated compression stocking prophylaxis
was even more effective when combined with another prophylactic technique (Amaragiri and Lees, 2000).
The optimal length of stocking required to prevent DVT
was the subject of a randomised study by Howard et al
(2004). This study recruited patients from a variety of
surgical specialties: breast and oncology (73 patients), ENT
(13), gastrointestinal (122), neurosurgery (34), orthopaedic
(62), urology (58) and vascular venous surgery (14). The
efficacy of stocking length in reducing DVT formation was
assessed against a background of low-molecular-weight
heparin (LMWH) thromboprophylaxis. The authors found
that the Medi Thrombexin climax thigh-length stockings were significantly better at preventing postoperative
DVT than the knee-length stockings (2 versus 11; OR 0.18;
95% CI 0.040782; P = 0.026) (Howard et al, 2004).
An alternative method of mechanical prophylaxis for
postoperative DVT/PE is the use of intermittent pneumatic
compression of the legs. A sequential compression device
consists of a microprocessor allowing pressurised air (e.g.
45 mmHg) into segmental compartments secured around
the leg for a fixed period of time (e.g. 11 seconds) (Auguste
et al, 2004). Sequential devices produce a wave-like
milking effect to evacuate the leg veins. This compression
may exert its prophylactic effect on thromboembolism,
partly by preventing venous stasis and partly from enhancing fibrinolysis. In one study, intermittent pneumatic
compression applied for 120 minutes to 21 male, nonsmoking volunteers ranging in age from 19 to 47 years was

associated with a significant increase in global fibrinolytic

potential (Giddings et al, 2004).
Ramirez et al (2003) audited the incidence of DVT
and/or PE in 1281 patients with colon cancer, rectal cancer or inflammatory bowel disease. All underwent major
abdominal or transabdominal pelvic surgery with their
thromboembolism prophylaxis being exclusively delivered
using sequential compression devices. Ten episodes of
venous thromboembolism were identified, for an incidence
of 0.78%. These included seven cases of thrombophlebitis
(incidence of 0.55%) and three cases of PE (incidence of
0.23%). Among the 944 patients who had surgery for colorectal cancer, the incidence of venous thromboembolism
(VTE) was 0.53%. Among the 337 patients who had major
surgery for inflammatory bowel disease, the incidence of
VTE was 1.48% (Ramirez et al, 2003). The authors concluded that VTE prophylaxis employing sequential compression devices alone does not result in a higher incidence
of VTE than the incidence reported for modern colorectal
practice. In addition, they suggested (Ramirez et al, 2003)
that because sequential compression devices are not associated with bleeding complications, advocating the use of
these devices in the highest-risk patients may increase surgeons compliance for VTE prophylaxis in those patients.

Heparin prophylaxis
Heparin is the dominant form of pharmacological prophylaxis against VTE in colorectal practice. About one-third of
an administered dose of heparin binds to antithrombin (AT)
and this fraction is responsible for most of its anticoagulant
effect (Hirsh et al, 2001). The heparinAT complex inactivates a number of coagulation enzymes, including thrombin factor (IIa) and factors Xa, IXa, XIa and XIIa. Of these,
thrombin and factor Xa are most responsive to inhibition
and human thrombin is about 10-fold more sensitive to
inhibition by the heparinAT complex than factor Xa (Hirsh
et al, 2001) (Table 3.24).
To inhibit thrombin, heparin must bind to both the
coagulation enzyme and AT, but binding to the enzyme is
less important for the inhibition of activated factor X (factor Xa). Molecules of heparin containing < 18 saccharides
do not bind simultaneously to thrombin and AT and are
therefore unable to catalyse thrombin inhibition. By contrast, very small heparin fragments containing the highaffinity pentasaccharide sequence catalyse inhibition of
factor Xa by AT. By inactivating thrombin, heparin not only
prevents fibrin formation but also inhibits thrombin-induced
activation of factor V and factor VIII. Unfractionated
heparin (UFH) and LMWH also induce secretion of the tissue factor pathway inhibitor by vascular endothelial cells.
This reduces procoagulant activity of tissue factor VIIa
complex and could contribute to the antithrombotic action
of heparin and LMWH (Hirsh et al, 2001).
The activated partial thromboplastin time (APTT) activity of heparin mainly reflects its antifactor IIa activity.
LMWH fractions prepared from standard commercialgrade heparin have progressively less effect on the APTT,
as they were reduced in molecular size, while still inhibiting activated factor X (factor Xa) (Hirsh et al, 2001). The
reduced antifactor IIa activity relative to antifactor Xa
activity of LMWH, combined with a better benefit-to-risk

Risk Management

TABLE 3.24

ANTIHAEMOSTATIC EFFECTS OF HEPARIN

Effects
Binds to AT-III and catalyses
inactivation of factors IIa,
Xa, IXa, and XIIa
Binds to heparin cofactor II
and catalyses inactivation
of factor IIa
Binds to platelets

Comments
Major mechanism for anticoagulant effect,
produced by only one third of heparin molecules
(those containing the unique AT-III-binding
pentasaccharide)
Anticoagulant effect requires high concentrations
of heparin and occurs to the same degree
whether or not the heparin has high or low
affinity for AT-III
Inhibits platelet function and contributes to the
hemorrhagic effects of heparin. High-molecularweight fractions have greater effect than
low-molecular-weight fractions

From Hirsh et al (2001).

ratio observed in animal experiments, have stimulated

interest in its clinical use (Hirsh et al, 2001). However, it is
the pharmacokinetic differences between LMWH and UFH
that are of most clinical importance (Hirsh et al, 2001)
(Table 3.25).
LMWHs produce a more predictable anticoagulant
response than unfractionated heparin, reflecting their better bioavailability, longer half-life and dose-independent
clearance (Weitz, 1997). Thus, when LMWHs are given
subcutaneously in low doses, the recovery of antifactor Xa
activity approaches 100%, compared with about 30% with
unfractionated heparin. The plasma half-life of LMWHs is
two to four times longer than that of unfractionated
heparin, ranging from 2 to 4 hours after intravenous injection and from 3 to 6 hours after subcutaneous injection.
The inhibitory activity of low-molecular-weight heparins
against factor Xa persists longer than their inhibitory activity against thrombin, reflecting the more rapid clearance
of longer heparin chains (Weitz, 1997).
In a Canadian multicentre, double-blind trial (McLeod
et al, 2001), patients undergoing resection of part or all of
the colon or rectum were randomised to receive, by subcutaneous injection, either calcium heparin 5000 units
every 8 hours (low dose unfractionated heparin; LDH) or
enoxaparin (LMWH) 40 mg once daily (plus two additional
saline injections). DVT was assessed by routine bilateral

TABLE 3.25
Preparation
Ardeparin
Dalteparin
Enoxaparin
Nadroparin
Reviparin
Tinzaparin

contrast venography performed between postoperative days

5 and 9, or earlier if clinically suspected. The venous
thromboembolism rate was the same in both groups:
44/468 or 9.4% (95% CI of the difference, 0 3.7%). Of
these, five were symptomatic (three in the LDH group, two
in the LMWH group). The rate of proximal DVT was 2.6%
in the LDH group and 2.8% in the LMWH group. No
instances of isolated iliac vein thrombosis were identified
by venography or ultrasonography; only one enoxaparin
patient had a symptomatic, non-fatal PE. No deaths were
attributable to thromboembolism. The total bleeding event
rate was significantly lower in the LDH group than in the
LMWH group (6.2% vs. 10.1%, P = 0.003), primarily
because of an excess of minor bleeding episodes in the
LMWH patients (P = 0.03). The rate of major bleeding
events was also increased, but not significantly (1.5% vs.
2.7%, 95% CI difference 0.4 to 2.8%; P = 0.136). Overall,
only three patients required reoperation for bleeding; none
of the patients died of a bleeding complication (McLeod
et al, 2001).
Data from the Canadian Colorectal Trial (Etchells et al,
1999) was used in an economic analysis of low-dose
heparin versus the LMWH enoxaparin for prevention of
venous thromboembolism after colorectal surgery. In this
analysis the relative risk of DVT and PE for enoxaparin
compared with low-dose heparin was 1.0 (95% CI

COMPARISON OF LOW-MOLECULAR-WEIGHT HEPARIN PREPARATIONS

Method of preparation
Peroxidative depolymerisation
Nitrous acid depolymerisation
Benzylation and alkaline depolymerisation
Nitrous acid depolymerisation
Nitrous acid depolymerisation,
chromatographic purification
Heparinase digestion

Mean molecular
weight
6000
6000
4200
4500
4000

Anti Xa:Anti IIa

ratio
1.9
2.7
3.8
3.6
3.5

4500

1.9

From Weitz (1997), copyright Massachusetts Medical Society. All rights reserved.

101

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Chapter 3

Perioperative Care

0.71.5) and the relative risk of major bleeding was 1.8

(95% CI 0.83.9). With the use of these data in the baseline analysis, a strategy of enoxaparin prophylaxis was
associated with equal numbers of symptomatic DVTs and
PEs, and an excess of 12 major bleeding episodes for
every 1000 patients treated, with an additional cost of
$86 050 (Canadian data) or $145 667 (US data). The
investigators (Etchells et al, 1999) concluded that
although heparin and enoxaparin are equally effective,
low-dose heparin is a more economically attractive
choice for thromboembolism prophylaxis after colorectal
surgery.
In the Cochrane Systematic Review (Wille-Jrgensen
et al, 2004), the efficacy of heparin and mechanical methods in thromboprophylaxis of patients undergoing colorectal surgery was considered. This review identified 558
studies, of which 477 were excluded. A total of 19 studies
entered the review, only three of which focused exclusively
on colorectal patients. The findings were as follows
(WilleJrgensen et al, 2004):

Heparins versus no treatment: any kind of heparin

compared to no treatment or placebo (11 studies).
Heparin is better in preventing DVT and/or PE, with a
Peto odds ratio at 0.32 (95% CI 0.200.53).
Unfractionated heparin versus LMWH (four studies): the
two treatments were found equally effective in preventing
DVT and/or PE, with a Peto odds ratio 1.01 (95% CI
0.671.52).
Mechanical methods (two studies): the combination of
graded compression stockings and LDH is better than LDH
alone in preventing DVT and/or PE, with a Peto odds ratio
at 4.17 (95% CI 1.3712.70).

The authors of the systematic review (Borly et al, 2005)

concluded that the optimal thromboprophylaxis in
colorectal surgery is the combination of graduated
compression stockings and LDH or LMWH.
A similar review (Bergqvist, 2004) identified a total of
16 comparative studies examining the role of heparin in
preventing thromboembolism after abdominal surgery
(Table 3.26). These showed that LMWH is as effective as
UFH in reducing VTE after abdominal surgery and, at

appropriate doses, can reduce bleeding complications. In

very high-risk patients, a higher dose of LMWH may offer
increased efficacy without increasing bleeding risk. In addition, Bergqvist (2005) concluded that extending the standard 710-day period of prophylaxis may benefit certain
high-risk groups.

Applying venous thromboembolism

prophylaxis
A major anxiety in VTE prophylaxis is that, despite institutional protocols, individual patients may be omitted from
these measures. Tooher et al (2005) identified six studies
that relied on the passive dissemination of guidelines (via
international or local publication) to change VTE prophylaxis practice. Adherence to guidelines and the provision of
adequate prophylaxis was poor in these studies, with no
more than 50% of patients receiving appropriate prophylaxis, despite dissemination of the guideline. By contrast,
the most effective strategies incorporated a system for
reminding clinicians to assess patients for venous thromboembolism risk, either electronic decision-support systems
or paper-based reminders, and used audit and feedback to
facilitate the iterative refinement of the intervention
(Tooher et al, 2005).
Mosen et al (2004) addressed the value of a computer
reminder system in improving the rate of VTE prophylaxis. A comparison was made of the rate of symptomatic
DVT/PE in patient groups: one group (2077 surgical
patients) receiving prophylaxis before the computerised
reminder system and a second group (2093 surgical
patients) whose venous prophylaxis was subjected to a
computerised reminder. The overall prophylaxis rate
increased from 89.9% before implementation of the
computerised reminder system to 95.0% after implementation (P < 0.0001). The combined 90-day rate of symptomatic DVT, PE and death attributable to PE remained
the same (preintervention 1.0%; postintervention 1.2%;
odds ratio 1.21; 95% CI 0.672.20). However, of the 46
venous thrombembolic complications, 87% (40/46)
occurred despite the delivery of American College of Chest
Physicians recommended measures to prevent VTE (Mosen
et al, 2004).

TABLE 3.26 SUMMARY OF COMPARATIVE CLINICAL TRIALS OF LOW-MOLECULAR-WEIGHT

HEPARIN (LMWH) PROPHYLAXIS IN COLORECTAL SURGERY
Trial design

No. of
patients

Double-blind
randomized
multicentre
Randomized
controlled

936

320

LMWH
versus
comparator
Enoxaparin
versus UFH

Once-daily
dose of
LMWH
40 mg s.c.

Enoxaparin
versus control*

40 mg s.c.
6.7 versus
1.8%

LMWH versus comparator

Safety
Major bleeding: 2.7 versus
1.5% (P = 0.136)
Bleeding complications:
(P = 0.045)
(P = 0.037)

Efficacy
VTE: 9.4% in both groups
Proximal DVT: 2.8
versus 2.6%
DVT: 0 versus 3%

From Bergqvist (2004).

*Control group had no prophylaxis.
DVT, deep vein thrombosis; s.c., subcutaneous; UFH, unfractionated low-dose heparin; VTE, venous thromboembolism.

Risk Management

VTE prophylaxis protocols should be included in surgical unit and ward guidelines, clinical pathways and resident medical officer manuals. Regular audits should be
undertaken of the extent and quality of VTE prophylactic
measures. There should be documentation in the case
notes of the VTE risk assessment for each patient and any
prophylactic measures that are used, mechanical (graduated compression stockings, intermittent pneumatic
compression) as well as pharmacological prophylaxis with
unfractionated heparin or LMWH (Fletcher, 2002).
After discharge home, the surgical patient can still be
vulnerable to VTE (Kearon, 2003). In orthopaedic surgery,
particularly in patients undergoing hip surgery, there is a
growing interest in using extended anticoagulation
beyond that traditionally given in the postoperative period
using LMWH, oral anticoagulants, or newer agents such
as fondaparinux sodium. Most studies show a benefit to
extending anticoagulation without a considerable increase
in major bleeding (Blanchard and Ansell, 2005). Hull et al
(2001) examined studies of out of hospital VTE prophylaxis with LMWH in patients undergoing elective hip surgery. Systematic review of six studies showed that,
compared with placebo, extended out-of-hospital LMWH
prophylaxis decreased the frequency of all episodes of deep
venous thrombosis [placebo rate 150/666 patients
(22.5%); relative risk 0.41; 95% CI 0.320.54; P <
0.001], proximal venous thrombosis [placebo rate 76/678
patients (11.2%); relative risk 0.31; 95% CI 0.200.47; P <
0.001] and symptomatic venous thromboembolism
[placebo rate 36/862 patients (4.2%); relative risk 0.36;
95% CI 0.200.67; P = 0.001]. Major bleeding was rare,
occurring in only one patient in the placebo group (Hull
et al, 2001).
Bergqvist et al (2002) examined the role of extended outof-hospital LMWH prophylaxis in patients undergoing open,
elective, curative surgery for a malignant tumour of the
gastrointestinal tract (other than the oesophagus),
genitourinary tract, or female reproductive organs. All
patients received 40 mg enoxaparin once daily, with the first
dose given 1014 hours preoperatively, for 610 days. After
this open-treatment period, the patients were randomly
assigned to receive 40 mg subcutaneous enoxaparin or
placebo once daily for 1921 days. The mean duration of
double-blind therapy was 19.5 days in the placebo group
and 19.3 days in the enoxaparin group. During the doubleblind period (Bergqvist et al, 2002), the overall incidence of
venous thromboembolism was 8.4% (28/332). In the group
given 1 week of prophylaxis (placebo group), the incidence
was 12.0% (20/167); in the group given 4 weeks of prophylaxis, it was 4.8% (8/165) (P = 0.02). This corresponds
to a reduction in risk of 60% (95% CI 1082). Proximal
deep vein thrombosis was identified in three patients in the
placebo group and one in the enoxaparin group. Similar
results have been described in colorectal cancer patients.
Rasmussen (2003) investigated 117 patents having surgery
for malignant disease (colorectal cancer resection in the
large majority) 63 of whom had no further thromboprophylaxis on discharge and 53 being given 4 weeks of out
of hospital prophylaxis with dalteparin 5000 IU daily.
Prolonged thromboprophylaxis with daltaparin in this cancer population reduced the incidence of all DVT from 15.9%

to 5.6% and reduced the incidence of proximal DVT from

15.9% to 0% (P < 0.005) (Rasmussen, 2003).
In general surgery, LMWHs are relied on more and
more for prophylaxis and initial anticoagulant treatment
of DVT, because of their multiple advantages in efficacy,
safety and convenience in handling (Gutt et al, 2005).
Newer anticoagulant molecules such as fondaparinux and
ximelagatran seem to have similar efficacy to LMWH in the
treatment of VTE, but they have a 2-fold increased efficacy
in its prophylaxis (Gutt et al, 2005). The new anticoagulants
can be classified as follows (Hoppener and Buller, 2005).
Tissue factor/factor VIIa inhibitors
The initiation of thrombus formation occurs when tissue
factor, exposed within a damaged blood vessel, rapidly
complexes with factor VIIa. A recombinant nematode
anticoagulant protein C2 (r-NAPc2), based on a substance
present in the saliva of the hookworm, is a potent
inhibitor of the tissue factor/factor VIIa complex.
Subcutaneous injection on alternate days is effective in
the prevention of venous thromboembolism after total
knee replacement.
Factor Xa inhibitors
Indirect inhibitors are synthetic analogues of the five key
sugars (pentasaccharides) present in heparin that specifically bind to the natural anticoagulant anti-thrombin, and
subsequently block factor Xa. Two pentasaccharides, both
administered subcutaneously, are now available: fondaparinux has a half-life of 1520 hours (which makes it
suitable for once-a-day administration) and idraparinux
has a half-life of about 130 hours (and so can be administered once a week).
The PEGASUS study (Bauersachs, 2005) compared the
efficacy and safety of fondaparinux with the LNWH dalteparin in the prevention of VTE in 2048 patients at high
VTE risk undergoing abdominal surgery. Compared with
dalteparin, fondaparinux reduced the incidence of VTE
from 6.1% to 4.6%, an odds ratio reduction of 25.8% (95%
CI 49.79.5%; P = 0.14) in favour of fondaparinux.
Among the 1408 cancer patients analysed for efficacy, fondaparinux significantly reduced the incidence of venous
thromboembolism from 7.7% to 4.7%, an odds reduction
of 40.5% (95% CI 61.97.2%; P = 0.02). There were
no significant differences between the two groups in the
incidence of major bleeding.
Thrombin inhibitors
The prototype of thrombin inhibitors is recombinant
hirudin. This is based on the anticoagulant produced by
leeches and can block thrombin independent of antithrombin; it is a direct inhibitor. Two clinical studies have shown
that hirudin, given subcutaneously, is more effective than
and as safe as LMWH in the prevention of VTE in patients
undergoing elective hip arthroplasty. Melagatran is another
direct thrombin inhibitor that must be given subcutaneously. At present, the greatest clinical need is for an oral
anticoagulant to replace warfarin for long-term prevention
and treatment of patients with venous and arterial thrombosis. Ximelagatran, an oral direct thrombin inhibitor,
might meet this need (Hirsh et al, 2005).

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Venal caval filters and venous

thromboembolism
Since the early 1900s, surgical interruption of the inferior
vena cava (IVC) has been utilised in the management of
VTE. Newer-generation percutaneous IVC filters were
introduced in the late 1970s and, since then, their use
and indications have expanded (Moores and Tapson,
2001). For those patients with established thromboembolic disease in which anticoagulation is either ineffective
or contraindicated, vena caval interruption is generally
accepted as the standard of care (Jacobs and Sing, 2003).
Other indications for filter insertion will remain a matter
for clinical opinion (Table 3.27). Girard et al (2002)
conducted a systematic MEDLINE search of vena cava
filters insertion and found a total of 568 references
between 1975 and 2000. Nearly two-thirds (65.0%) of
these publications were retrospective studies or case
reports (33.3% and 31.7%, respectively), 12.9% were animal or in vitro studies, 7.4% were prospective studies,
6.7% were reviews and 8.1% reported on miscellaneous
related topics. Among the prospective studies, only 16
studies included 100 patients and only one was an RCT
(0.02% of 568 references).
Complications of IVC filter use include acute procedurerelated complications: misplacement (1.3% of insertions),
pneumothorax (0.02%), haematoma (0.6%), air embolism
(0.2%), inadvertent carotid artery puncture (0.04%) and
arteriovenous fistula (0.02%) along with a placement mortality of 0.13% (Hann and Streiff, 2005). Longer-term
problems include insertion-site thrombosis, recurrent DVT,
IVC thrombosis, filter migration, IVC penetration and filter
disruption.
IVC thrombosis is of concern because this can lead to
phlegmasia cerulea dolens, recurrent DVT and a heightened risk of post-thrombotic syndrome and recurrent PE
due to thrombi, which extend proximal to the thrombosed
filter (Hann and Streiff, 2005). Thus Crochet et al (1999)
found a progressive decrease in IVC patency in 142 patients
managed with a Vena Tech-LGM filter, reaching 66.8% at
9 years of follow-up. Complete caval occlusion occurred in
28 patients and was significantly associated with retraction in 24 cases. IVC occlusion was not related to age, sex,
PE, DVT level, underlying conditions predisposing to a
thromboembolic disease before filter insertion, the level of

TABLE 3.27

filter placement, use of anticoagulant therapy or death

during follow-up.
However, post-thrombotic syndrome is also a common
complication among patients not treated with an IVC filter
for VTE (Hann and Streiff, 2005). Compression stockings
may have a role in reducing the incidence of post-thrombotic syndrome: in one study (Brandjes et al, 1997), 194
patients with a first episode of venogram-proven proximal
DVT were randomly assigned compression stockings (n =
96) or no stockings (n = 98). After a median follow-up
of 76 months (range 6096) mild-to-moderate postthrombotic syndrome occurred in 19 (20%) patients in the
stocking group and in 46 (47%) control-group patients
(P < 0.001), while severe post-thrombotic syndrome
was seen in 11 (11%) patients in the stocking group (score
4), compared with 23 (23%) patients in the control group
(P < 0.001). Routine use of compression stockings should
be encouraged among all filter patients (Hann and Streiff,
2005).
Given the long-term complications of permanent filters,
development of a safe and effective temporary filter has
been proposed as an alternative to a permanent filter in
patients who have an acute episode of VTE and a shortterm contraindication to anticoagulation. Two types of
removable filtering device are currently available (Jacobs
and Sing, 2003): temporary filters and retrievable filters.
The temporary filter remains attached to an accessible
transcutaneous catheter, or guidewire, so that removal of
the filter is easily accomplished and is mandatory. These
devices, however, carry a higher risk of insertion-site
infection, filter thrombosis and filter dislocation.
Retrievable filters, like permanent filters, are freestanding endovascular devices that require repeat endovascular access to accomplish their removal. If, however, the
patients need for temporary PE prophylaxis becomes permanent, these filters may be left in place and treated in a
fashion similar to that of permanent IVC filters (Jacobs and
Sing, 2003). Previously, if temporary IVC filtration was
the desired goal then filters could not be left in place for
longer than 10 days, as endothelial incorporation of the
filter might complicate removal if left too long (Jacobs and
Sing, 2003). The recovery nitinol filter (RNF), however,
can be safely removed up to 134 days after implantation
(Asch, 2002).

INDICATIONS FOR INFERIOR VENA CAVA (IVC) FILTER PLACEMENT

Appropriate indication
Contraindication
to anticoagulation
in established
thromboembolic
disease

Potential indication
Failure of adequate anticoagulation
Pulmonary thromboembolectomy patients
Prophylaxis in high-risk trauma patients
Extensive free-floating iliofemoral thrombus
Thrombolysis of iliocaval thrombus

Unsubstantiated indication
Treatment of VTE in:
Cancer patients
COPD patients
Patients with poor cardiopulmonary reserve
Pregnant patients
Organ transplant patients
Patients with history of GI bleed
Prophylaxis in burn patients
Prophylaxis in bariatric surgery patients

Based on Hann and Streiff (2005).

COPD, chronic obstructive pulmonary disease; GI, gastrointestinal; VTE, venous thromboembolism.

Risk Management

TRANSFUSION AND BLEEDING

Most colorectal surgical resections can be performed without the transfusion of blood or blood products. Mynster
et al (2004) compared blood loss associated with rectal
cancer surgery before (n = 246; 19913) and after the
introduction of total mesorectal excision (n = 311;
19968). The median intraoperative blood loss was 1000
mL (range 506000 mL) before and 550 mL (range
106000 mL; P < 0.001) after introduction of TME. The
overall perioperative transfusion rate was reduced from
73% to 43% (P < 0.001). When adjusted for blood loss,
age, gender, weight and type of resection, TME significantly
reduced the risk of receiving intra or postoperative blood
transfusion by 0.4 (95% CI 0.30.6).
Thus, most operations can be performed safely in those
with faith issues that make transfusion an ethical dilemma
(Gohel et al, 2005). Preoperative patients with anaemia or
clotting deficiency should be treated by appropriate replacement therapy before elective operative intervention.
Okuyama et al (2005) demonstrated that, in anaemic colorectal cancer patients, iron supplementation for at least 2
weeks before surgery reduces the need for intraoperative
transfusion. Of 569 patients who underwent colorectal
cancer surgery between 1998 and 2003, 32 anaemic
patients received iron supplementation for at least 2 weeks
preoperatively (group A) while 84 anaemic patients did not
(group B). Anaemia was defined as a haemoglobin level at
first presentation of 10.0 g/dL. There were no significant
differences between groups A and B in age, sex, surgical
technique, tumour stage and operating time. Their haemoglobin and haematocrit values were similar at first presentation, but significantly different immediately before
surgery (both P < 0.0001). There were no significant differences in intraoperative blood loss between the groups
but significantly fewer patients in group A needed an intraoperative blood transfusion (9.4% versus 27.4%; P < 0.05).
Cross-matching blood is necessary for tumours requiring
extensive resection (pelvic exenteration) or in patients with
chronic sepsis needing surgical interventions. Nakafusa et al
(2004) compared transfusion requirements in locally
advanced colorectal cancer with and without multivisceral
resection. Of 323 patients, 53 (16.4%) received multivisceral
resection because of adhesion to other organs. Multivisceral
resection was significantly associated with tumour size,
depth of invasion, operative blood loss, operation time, and
blood transfusion (all: P < 0.0001).
Massive bleeding is uncommon in colorectal practice,
alarming haemorrhage is usually venous. Arterial bleeding, which can be annoying because access is often poor,
may be encountered from the internal pudendal vessels or
branches of the internal iliac artery. Venous bleeding can
be difficult to control if veins near the confluence of the
right colic vessels or the superior mesenteric vein are
injured or if splenic hilar vessels are torn. The most alarming form of blood loss to the relatively inexperienced colorectal surgeon is from presacral veins. Bleeding can be
extensive, the pelvis simply fills up with low-pressure
venous blood. van der Vurst et al (2004) encountered this
problem in five of 165 patients (3%) who underwent a presacral dissection for rectal mobilisation. In these five cases,
successful tamponade of presacral haemorrhage was

obtained using absorbable haemostatic sponges fixed to the

sacrum with endoscopic helical tackers.
Placing the patient in the steep Trendelenburg tilt so
that the veins are no longer dependent and packing the
pelvis tightly allows the surgeon to pursue another part of
the operative procedure. If the pelvis is not dry when the
packs are removed 1 hour later, then the pelvis should
be repacked through the perineum if the procedure has
been an abdominoperineal excision (or proctocolectomy) or
through the abdomen (Metzger, 1988). Application of
haemostatic gauze to the haemorrhaging point is maintained by the pressure of several lengths of 6-inch ribbon
gauze. The gauze may be used dry and the patient is postoperatively nursed in an ITU or HDU setting. Packs are left
in place for 4872 hours while coagulation studies and the
patients haemoglobin are normalised.
Care should be exercised when removing the packs.
Pulling adherent gauze from the sacral fascia may cause
further bleeding. Packing the gauze into an intestinal bag
has been described as a technique to prevent haemostatic
packs adhering to the sacrum.
The patient should be returned to the operating room
for removal of the pack with the personnel and equipment
available for a full laparotomy, if pelvic haemorrhage
resumes on removal of the pack. In selected cases, leaving
the ends of the gauze packs emerging from the lower end
of the laparotomy wound allows removal in some instances
without laparotomy. Alternatively pack removal is carried
out via a formal laparotomy when pelvic haemostasis can
be checked under direct vision as the packs are removed
(Curran and Scott, 2005).

COLORECTAL PATIENTS AND HIGHDEPENDENCY CARE: EVOLUTION OF THE

SURGICAL HIGH-DEPENDENCY UNIT
Traditional postoperative care for abdominal procedures in
colorectal patients has been provided by either general
ward care or by ITU provision. Two separate observations
have identified the need for care provision intermediate
between these two levels. First, that within the workload of
a general ITU it has become apparent that a significant population is at relatively low risk and might be cared for in an
intermediate facility. Thus, Kilpatrick et al (1994) found
that among 1168 ITU admissions, 40% of patients were
admitted with a risk of hospital mortality of 10% or less:
such patients received only a short period of intensive care
and had a low mortality in the intensive therapy unit. The
authors (Kilpatrick et al, 1994) proposed that a group of
patients with a low predicted (and actual) mortality rate
might be more appropriately managed on a high-dependency unit. Second, it has become apparent from a surgical
perspective that continuous monitoring of some patients
is required in a unit that provides a specified increased
patient to nurse ratio: a surgical high-dependency unit
(HDU) (Crosby and Rees, 1994, Edbrooke, 1996).
In a survey of Scottish HDU provision, surgical HDUs
account for 41% of the HDUs, 24% are mixed (i.e. covering both medical and surgical), 16% are combined ICU/
HDU, 11% are medical and 8% are neurosurgical (see:
http://www.scottishintensivecare.org).

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Coggins (2000) similarly demonstrated that in a hospital without a surgical HDU, at least 5% of the beds on a
general surgical ward are occupied by inappropriately
placed HDU patients. Moreover, the needs of such patients
has an impact on the number of observations made on the
more routine patientsthe mean of 5.1 observations every
24 hours falling to 3.8 every 24 hours in the presence of
an HDU patient (P < 0.02). Accordingly, in UK practice the
provision of surgical HDU has developed on an ad hoc basis
out of and alongside the ITU. Nehra et al (1994) proposed
that a 250 000-population UK district general hospital
would require a six-bed ITU and eight high-dependency
surgical beds in two separate but adjacent units, where
there will be a free interchange of skills at the different
levels of care.
Attempts to demonstrate that the introduction of a surgical HDU will reduce surgical mortality can be confounded
by other variables in a hospitals casemix. Thus, in one hospital the first 12 months of HDU utilisation was associated
with an increase in overall surgical mortality from 2.16%
to 3.2%; however, in the same 12 months there was a disproportionate increase in emergency admissions (27%)
and emergency out-of-hours operating (12%) (Davies et al,
1999). A more telling demonstration of surgical highdependency care on surgical outcomes is provided by a
study of 1363 patients undergoing a range of surgical procedures. Postoperatively, 349 were judged by the surgeon
and anaesthetist to require HDU provision but only 140
(42.3%) actually received HDU care. In the group of
patients that received optimal postoperative care, the mortality rate was 1.2%significantly better than the 3.1%
mortality rate observed among those not receiving the care
level requested (Turner et al, 1999).
Further evidence for a specific HDU effect on preventing postoperative morbidity comes from comparison of
outcomes between a surgical population managed on a
general ward in a hospital with no HDU and a similar surgical population managed in the HDU of a second hospital (Jones et al, 1999). Ideally, this study would have been
carried out in the same institution but the two groups
were very comparable in their physiological and operative severity scores. A surgical HDU association was seen
in reducing postoperative morbidity, specifically reducing
chest infections (25% versus 41%), prolonged hypotension (1% versus 14%) cardiac dysrhythmia (7% versus
13%) and wound infection (2% versus 17%) (Jones et al,
1999).
Step-down from ITU care is another function of surgical HDU care in the management of colorectal patients.
Papagrigoriadis et al (2004) described the hospital care
of 148 patients with diverticular disease. Of 982 hospital days, 94 were on an ICU and 68 were on a surgical HDU
(Papagrigoriadis et al, 2004). Boots and Lipman (2002)
describe the potential of every patient in the ICU to be at
some time classifiable as an HDU patient. In their view, only
if there is a need for monitoring for more than 1224
hours should a patient move from the ICU to the
HDU rather than being discharged to the ward. Other
advantages to surgical HDU care include:

Increased patient and nursing satisfaction with the level

of care delivered (Armstrong et al, 2003).

A consistent and valuable clinical resource for teaching

and learning in surgical education and training (Ghosh
et al, 2004).

Surgical high dependency unit care

De Silva et al (2001) used the Logistic Organ Dysfunction
System (LODS) to monitor patient progress in a predominantly surgical HDU, concentrating on a subset of 100
patients whose stay on the unit was greater than 48 hours,
representing 14.5% of the total HDU admissions over the
study period. Sixty-six patients LODS scores improved
during their HDU admission, whereas in 20 patients the
LODS scores remained the same and for 14 the LODS score
increased. These 14 patients were older than the other
patients and required longer HDU admission; the 14
includes the two patients who died and the patient transferred to the ICU (De Silva et al, 2001).
Care within a surgical HDU is likely to reflect the patient
casemix and the evolution of local policies in the provision
of critical care. For now, the colorectal surgeon is still
expected to manage patient illness that commonly arises
after colorectal surgery. The clinical roles of the surgical
HDU include accurate fluid management, invasive monitoring, good oxygenation and optimal pain relief. In addition, the surgical setting of the HDU acts to maintain the
involvement of the operating surgeon in the critical care of
the patient in whom they have undertaken a procedure
(Coggins and Cossart, 1996). For the minority of patients
who require extended HDU care, nutritional assessment is
also required. Kinn and Scott (2001) examined HDU-based
nutritional care. They found that the most common form
of supplementary feeding was total parenteral nutrition
(TPN), the choice of supplementary feeding being dependent on the type of surgery and the individual patients
condition.
The Scottish Intensive Care Society conducted a telephone questionnaire in April 2000 to assess the provision
of high-dependency care beds across Scotland. As well as
identifying the number of HDUs and their bed complement,
the survey assessed the extent of the variation in nursing
provision and the range of critical care interventions that
each unit could provide. Almost every acute hospital had
high-dependency facilities available for surgical patients.
Surgical HDUs provide transduced monitoring of central
venous and intra-arterial pressures, and the majority are
able to infuse inotropes and care for patients with
tracheostomies (Figure 3.9).
Ng and Goh (2002) studied 471 patients that had
epidural catheters inserted for postoperative analgesia.
Ninety per cent of patients received continuous local anaesthetic infusion (75% ropivacaine and 15% bupivacaine) and
10% received intermittent morphine boluses. There were
few serious complications but 60% of patients required one
or more interventions, mainly for inadequate analgesia.
One-third of patients had their epidural analgesia terminated prematurely due to inadequate analgesia (14.2%),
shortage of beds in the HDU (14%) and other complications.
Only 19% of patients had no reported adverse effects.
Coggins et al 1998 documented changes in pain relief techniques in surgical HDU admissions (Figure 3.10), with a
large increase in the use of epidural analgesia.

Risk Management

Figure 3.9 Interventions in Scottish

high-dependency units.

100
90
Percentage of units

80
70
60
50
40
30
20
10
0
al

ur

d
pi

VP

lin

ito

in

on

ri

te

Ar

l
al

EC

e
tro

In

PA

be

as

pe

ch

a
Tr

ET

tu

PA

te

tio

ca

e
th

Ve

a
til

na

Re

Intervention

majority of these patients. Equal numbers of supraventricular and ventricular arrhythmias were detected, atrial
fibrillation being the most commonly detected abnormality. Therapeutic intervention (electrolyte correction and
anti-arrhythmic agents) was required in 23 patients. One
patient required DC shock for ventricular fibrillation. Seven
patients were transferred to the heart-care unit or intensive care unit to manage their cardiac problems. Two
patients died as a result of their cardiac problem and 27
were discharged home alive, three on long-term antiarrhythmic therapy.
The key to successful HDU care is multiprofessional
team care in which the surgical team, HDU nurses and
anaesthetic/intensivist colleagues assess patients for postoperative organ dysfunction and intervene early to prevent
organ failure. In this context, the following represent common HDU assessments and interventions.

250

200

150

100

50

0
199192

199293

Epidural
CVP
IV analgesia

199394

199495

Patient controlled
analgesia
Thrombolysis

Figure 3.10 Changes in epidural use in surgical highdependency unit admissions. From Coggins et al (1998).

Batra et al (2001) reported on 226 colorectal patients

(colorectal cancer and inflammatory bowel disease) admitted to a surgical HDU over a 12-month period. A total of
29 patients (13%) had significant arrhythmias on ECG
monitoring (median age 74 years, range 3588 years).
Pre-existing ischaemic heart disease, which was present in
nine patients, accounted for the underlying problem in the

ANAESTHESIA FOR COLORECTAL SURGERY

Preoperative assessment
Adequate preoperative assessment is important to identify existing medical conditions, potential anaesthetic difficulties and to plan perioperative care. It also gives an
opportunity for the patient to receive an explanation of
the anaesthetic and ask questions. Patients should always
be seen by an anaesthetist preoperatively, but basic
screening and assessment can be organised in a variety
of ways. Trained nurses, working to agreed protocols, can
identify patients who need minimal investigation or those
who require further assessment and referral. This
arrangement can improve efficiency and enhance patient
care. All patients with intercurrent disease should have
their condition optimised prior to surgery. Very few
patients will be deemed unfit for anaesthesia but many
are ill-suited to the stress of the intended procedure and
may be predicted to have a difficult postoperative course.

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Oxygenation and respiratory function

Monitoring
Respiratory rate
Pulse oximetry

Assessment
Clinical examination/chest X-ray,
ABGs, ARDS

Interventions
Increase FiO2
CPAP
ITU referral

ABG, arterial blood gases; ARDS, acute respiratory distress syndrome; CPAP, continuous positive airway
pressure; ITU, intensive treatment unit.

Haemodynamic stability
Monitoring
Pulse rate
Blood pressure
Urine output

Assessment
Clinical examination
Observation trends

Interventions
Fluid bolus
Exclude haemorrhage
Dopamine
ITU referral

Assessment
Clinical examination
Respiratory effort

Interventions
Epidural adjustment
PCA

ITU, intensive treatment unit.

Analgesic requirements
Monitoring
Pain score

PCA, patient controlled analgesia.

Cardiac arrhythmia
Monitoring
ECG trace

Assessment
Clinical examination
K+/Mg2+
Acidbase balance

Interventions
Correct electrolytes
ITU/cardiology consult
(anti-arrhythmic
drugs/DC shock)

ITU, intensive treatment unit.

It is inappropriate to discuss detailed preoperative assessment here and general references are given at the end of
the chapter. It is, however, sensible to list some of the
common problems that affect the management of anaesthesia and recovery, many of which not infrequently slip
through the net.
Cardiovascular disease

masked by postoperative analgesia and the episode can

present as an acute confusional state. Diagnosis is clinical
and by ECG and isoenzyme changes. Because of the relatively high incidence of incidental abnormalities, all
patients over 60 years old should have a recent preoperative ECG available for comparison. Echocardiography may
be valuable to assess left ventricular function and any
valvular abnormality.

Ischaemic heart disease

Ischaemic heart disease is commonoften occultand

there may well be no signs or symptoms present. Any
maintenance therapy should be continued peroperatively.
Postoperative hypoxia can precipitate cardiac ischaemia
and compromise pump function. Cardiac pain may be

Hypertension

Hypertensive patients are at increased risk during

the perioperative period. Complications of hypertension
include ischaemic heart disease, heart failure, cerebrovascular disease and renal impairment. The presence of

Risk Management

these is a major contribution to perioperative cardiac risk.

Repeated measurements should be taken to minimise the
effect of white coat hypertension. Investigations should
include:

ECG: no evidence of left ventricular hypertrophy,

conduction abnormalities or dysrhythmias.
Chest X-ray: no evidence of ventricular dilatation.
Full blood count: no evidence of polycythaemia.
Urea and electrolytes: no evidence of renal/endocrine
involvement. Mild hypokalaemia is unlikely to be associated with intraoperative dysrhythmias but levels below
3 mmol/L should probably be treated.
Serum glucose: not diabetic.

Although the evidence is unclear, it would seem sensible to

postpone patients for routine surgery who have a systolic
blood pressure > 180 mmHg or a diastolic pressure of
> 110 mmHg. Blood pressure is best normalised over a period
of weeks although in urgent cases this may not be possible. Very rapid control of blood pressure may increase morbidity and mortality. The problems specific to hypertensive
patients are the following:

There is a greater blood pressure lability especially during

induction and at laryngoscopy.
Arrhythmias are more common.
Increased levels of afterload and cardiac work predispose
to myocardial ischaemia and infarction.
Interactions may be anticipated between antihypertensive and anaesthetic agents.

Perioperative care may require invasive monitoring and

admission to an HDU. It is important to prescribe postoperative maintenance therapy. As the oral route is usually
inappropriate following colonic surgery this implies a
change to a parenteral or alternative preparation.
Pulmonary disease
Chronic obstructive airways disease

Patients with chronic obstructive airways disease

(COAD) have a 20-fold increase in postoperative pulmonary complications compared to healthy adults.
Preoperative assessment and treatment should be aimed
at optimising the patients respiratory status. A history
of dyspnoea, limitation of physical activity, sputum production and clinical examination give a good indication
of the patients pulmonary function and are usefully
augmented with arterial blood gas analysis and lung
function tests.
Although in many cases the likely outcome is easy to
predict, the only studies of the results of preoperative
lung function tests to postoperative complications relate
to lung resections. Some general deductions can,
however, be made. If the tidal volume (VT) is close to the
vital capacity (VC), then there is little ventilatory reserve
and the adequacy of postoperative ventilation easily
deteriorates with opioids and residual neuromuscular
block (including that provided by a thoracic epidural).
Irrespective of the cause, perhaps the most important
feature of low values of the forced expiratory volume in
1 second (FEV1) and the peak expiratory flow rate (PEFR)
is an indication that the patient cannot expel air rapidly.

Although these tests are not a direct measure of the

power of a cough, they are closely related to the ability
to expel sputum. An FEV1 of < 2 L or an FEV1 : VC ratio
of less than 50% are sometimes quoted as values which
define serious disease.
Arterial blood gas analysis showing a pO2 less than 7.1
kPa in association with dyspnoea at rest predicts dependence on respiratory support postoperatively in upper
abdominal surgery. A raised pCO2 may indicate a patient is
functioning on a hypoxic respiratory drive and will require
controlled oxygen therapy postoperatively.
All patients with significant pulmonary dysfunction
need to be cared for postoperatively in an appropriate
setting. This care needs to include regular observations to detect and treat hypoxia and meticulous attention to fluid balance and analgesia. Pulse oximetry can
be invaluable.
Asthma

In addition to clinical assessment the most sensitive indices

of bronchial tone are the PEFR and FEV1. Bronchospasm
and infection should be controlled prior to elective surgery
and it is important to allow patients to continue their normal medication up to the time of operation. Prophylactic
antibiotic therapy is indicated for people with severe
asthma. All patients need a chest X-ray, both as a baseline
and to show the presence of bullae and hyperinflation.
The three most common problems during anaesthesia
are bronchospasm on intubation or during gas induction,
the risk of a pneumothorax when on intermittent positive
pressure ventilation (IPPV) and bronchospasm secondary
to thiopental or other histamine-releasing drugs such as
atracurium, suxamethonium, morphine, etc.
Adequate premedication is important if the patient is
nervous, because an attack can be precipitated by fear.
An asthmatic attack in the postoperative period should
be treated in the normal way. Maintenance therapy may
need to be changed from the inhalation to the parenteral
route in the immediate postoperative period.
Diabetes
Approximately one-quarter of all diabetic patients undergoing surgery are undiagnosed on admission to hospital.
Almost all of these fall into the adult onset type, i.e. individuals who have a small but insufficient insulin production. It is therefore necessary to have a high index of
suspicion that diabetes may be present in any patient, especially if obese and over 60 years old. The stress of surgery
may precipitate frank diabetes in a previously undiagnosed
patient.
Diabetes has widespread physiological effects relevant
to preoperative assessment, the most important of which
are listed systemically below.

Cardiovascular effects: evidence of angina, myocardial

infarction, intermittent claudication, gangrene and postural hypotension (systolic fall of > 30 mmHg on standing) should be sought.
Neurological complications: neurological involvement may
be evident as numbness, pain, paraesthesia, leg ulcers,
strokes, transient ischaemic attacks, impotence or gustatory

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sweating. Postural hypotension is a late sign of autonomic

neuropathy; loss of heart rate variability during deep
breathing is the most reliable early sign.
Renal complications: range from minimal proteinuria to
chronic renal failure with secondary complications of
anaemia and/or hypertension.
Skin: staphylococcal infections are common and there is
an increased risk of sepsis, especially over the pressure
areas.

Most of the excess perioperative mortality of diabetes is

related to cardiovascular comorbidity but good metabolic
control is also important. Non-insulin-dependent diabetics
can usually be managed by omitting their hypoglycaemic
on the morning of surgery but insulin-dependent diabetics
and all those undergoing major surgery will require insulin
perioperatively. Regular blood glucose estimations and
adherence to local protocols are vital to safe management.
Bowel preparation
Bowel preparation agents (e.g. Picolax) may lead to marked
dehydration and subsequent hypotension and oliguria
intraoperatively. Patients should be encouraged to drink
adequate amounts orally or receive intravenous fluids
preoperatively.
Selection for day-case surgery
Many minor surgical procedures may be considered to be
appropriate for admission as day cases. The surgical
procedures should usually last no longer than an hour,
although no absolute time limit is necessary. Patients
should be assessed for their suitability on both medical and
social criteria and this requires preoperative screening and
consistent protocols in each unit. They should be in good
general health and any chronic disease (e.g. asthma, diabetes, epilepsy) should be well controlled. Grossly obese
patients should be excluded. Patients need to be accompanied home, have an adult carer for at least 24 hours, have
access to a telephone and be able to return easily to the
hospital if problems occur.

Intraoperative techniques
For the well-prepared elective bowel resection, the requirements are abdominal muscle relaxation and lack of
response to surgical stimulae, preferably with contracted
intestines. This state of anaesthesia can be achieved by general or local techniques, or by a combination of both. In
the UK, the majority of colonic resections are done under
general anaesthesia using muscle relaxation. This gives a
smooth intraoperative course but can produce problems
during reversal and postoperatively (see below).
Increasingly, anaesthetists are combining general anaesthesia (to achieve unconsciousness) with some form of
regional blockade (to achieve analgesia), which can be carried into the postoperative period for pain relief. Patients
with a dense regional blockade who are awake during surgery are rarely seen in the UK, although it is not uncommon in some other European countries such as Sweden. In
certain instances (e.g. intestinal obstruction), the condition dictates specific techniques (e.g. rapid sequence induction with cricoid pressure in order to prevent aspiration
pneumonitis).

Local anaesthetic techniques

Local anaesthetic techniques have an undeserved reputation for safety (particularly in the compromised patient),
which tends to obscure their dangers. All local anaesthetics can produce direct toxicity and adverse side-effects. It is
important that those who employ them can recognise and
treat these complications. For this to be so, local anaesthetics should be used only in environments where full
resuscitation facilities and the staff who know how to use
them are available. A surgical procedure in a fully conscious patient should not be pushed on to unwilling or
nervous patients and all members of the operating theatre
staff need to know and to be constantly reminded that the
patient is awake.
For colorectal surgery there are only a limited number
of ways in which local blocks can be used and none of
them interrupt the vagus nerve. This can be a nuisance
because traction on the mesentery and viscera often results
in unwanted bradycardia and, in the awake patient, can
produce intense nausea.
Infiltration

This is suitable only for operations on the anal canal, where

it can be very successful. From a point 2.5 cm posterior to
the anus (with the index finger of the left hand in the
rectum), 25 mL 1.5% lidocaineadrenaline solution is
injected. Only one site of injection is necessary and
the anus and anal canal are ensheathed by a cylinder of
solution. Local infiltration is very successful in suitably
selected patients having sphincterotomy excision of anal
skin tags (often with rubber band ligation) and around a
low lying anal fistula being laid open. Local infiltration can
also be used for excision of pilonidal sinus if simple and
excision of condylocmata.
Caudal block

This is a form of epidural blockade achieved through the

sacral hiatus. It is usually performed as a one-shot procedure and requires proper sterile precautions. The sacral
canal, in addition to housing the nerves to be blocked, also
contains the dural sac (usually attached to the second
sacral vertebrae), and a venous plexus. It is therefore quite
possible to inject large quantities of local anaesthetic solution both intravascularly and into the subarachnoid space:
both of these events can be disastrous if not detected and
treated promptly.
When local anaesthetic solution is injected into the
sacral canal it ascends upwards in the extradural space for
a distance proportional to the volume of the solution, the
force of injection, the amount of leakage through the eight
sacral foramina, and the consistency of the connective tissue in the sacral space. While the first two are controllable,
the last two are not and unexpected results can occur. In
an average man, 30 mL of local anaesthetic solution will
block to L2L4 (the whole perineal area) and 20 mL will
suffice for haemorrhoids or anal fissure. If surgeons do not
like a relaxed anal sphincter during surgery, the block can
be instituted after surgery but before awakening, for postoperative pain relief. Urinary retention is an easily missed
complication of the block which, in the elderly, can present
as confusion.

Risk Management

Epidural block

This is blockage of the nerve roots outside the dura. Within

the relevant peripheral nerve distribution it gives relaxation
of muscles, analgesia and a degree of hypotension dependent upon the extent of sympathetic blockade. Unless the
block goes to an unpredictably high level it allows spontaneous respiration with the diaphragm, although the intercostals may be compromised. Like other forms of regional
blockade it suppresses afferent impulses secondary to
painful stimuli and the hormonal and autonomic responses
to surgery. A catheter is usually introduced into the
epidural space so that the block can be continued into the
postoperative period. One of the advantages of epidural
blockade is that it allows a band of analgesia to be
established without paralysis of the lower limbs.
When the epidural space has been identified, the extent
of the block is influenced by the volume and concentration
of solution injected, the age of the patient (the aged need
less), the location of the catheter (thoracic segments need
less than lumbar segments for each dermatome), the length
of the vertebral column and the presence of large abdominal
tumours. The exact extent of block secondary to a given
volume of local anaesthetic is unpredictable to a high
degree of accuracy.
Epidural blockade has several complications, which can
occur during top-ups on the postoperative ward as well as
at the time of insertion. Those most likely to cause
problems are:

Inadequate block, unilateral block or missed segments.

Hypotension and cardiovascular depression from sympathetic blockade. This requires oxygen, intravenous
solutions, pressor drugs and, if there is a bradycardia,
atropine.
Toxicity due to absorption of the injected drug (either
local anaesthetic or opioid).
Unexpected respiratory depression.
Unexpected total spinal anaesthesia, sometimes from
migration of the catheter into the subarachnoid space.
This is life threatening and requires immediate action.
A typical dose of epidural local anaesthetic (10 mL) is
approximately five times the volume of drug required to
produce the same level of block when injected into the
subarachnoid space.
Nausea, vomiting and shivering.
Unexpectedly prolonged analgesia.

Because of the potential complications of epidural analgesia, all patients receiving it postoperatively should be
nursed in a suitable environment with ready access to
anaesthetic support. All catheters should be inspected after
removal and recorded as being intact. Although extradural
abscesses are rare, many anaesthetists are reluctant
to establish or continue with epidural analgesia in the
presence of systemic sepsis.
Other absolute contraindications to regional blockade
are local sepsis, patient refusal and the presence of a coagulopathy or therapeutic anticoagulation because of the risk
of epidural haematoma formation and subsequent neurological damage. There is controversy concerning the use of
these techniques in patients receiving prophylactic lowdose heparin or aspirin. There is no firm evidence that this

will increase the risk of epidural haematoma and a

balanced judgement as to the risks and benefits of the
technique needs to be taken for each patient. If possible,
regional anaesthesia should be undertaken before the first
dose of unfractionated heparin is given or delayed until
6 hours after the previous dose (Bullingham and Strunin,
1995). A 12-hour interval has been recommended
following low molecular weight heparin. Similarly, some
would consider that aspirin therapy should ideally be
stopped for 710 days before instituting a regional block
or before a bleeding time is performed.
Other relative contraindications include neurological disease and some forms of cardiac disease (e.g. aortic
stenosis).
Subarachnoid (spinal) block

Subarachnoid block entails performing a lumbar

puncture and injecting local anaesthetic directly into the
cerebrospinal fluid (CSF). Although the use of very fine
catheters has been reported, spinal block is essentially a
single-shot technique.
Unlike epidural block, when local anaesthetics are
injected into the subarachnoid space they effectively produce a pharmacological transection of the cauda equina
and spinal cord at the upper level of the solution. There is
no sparing of any fibres or tracts and if the abdomen is to
be anaesthetised then the lower limbs are automatically
paralysed. The highest dermatome reached depends on
the volume and concentration of solution, the force and
rate of injection, the position of the patient, the interspace
chosen and the specific gravity of the solution.
The most common intraoperative complication is a fall
in blood pressure from sympathetic blockade, which, if necessary, is treated with fluid and vasoconstrictors. As long
as the block is acting, retention of urine remains a possibility and the immobility of the patient may lead to
ischaemia over pressure areas. If the block does not start
to regress at the expected time the anaesthetist should be
contacted at once.
The most common postoperative complication is
headache. The classic spinal headache is a low-pressure
headache that is worse in the upright posture and relieved
by lying down, and may be associated with meningism and
photophobia. It is seen most commonly in young adults
(females more than males) and is closely related to the
size and type of needle used; the larger the needle, the
greater the incidence of headache. The majority of spinal
headaches can be managed by bed rest, adequate hydration and simple analgesics. If the headache does not settle
within a day or so, consideration should be given to performing an epidural blood patch.
The introduction of pencil-point needle tips and finergauge needles have significantly lowered the risk of postdural puncture headaches and hence spinal techniques
may be satisfactory for day patients.
Anastomosis and anaesthesia
Morbidity and mortality from gastrointestinal complications
can result indirectly from the effects of anaesthesia on cardiovascular and respiratory function, or directly from the
effects of drugs and anaesthetic manoeuvres on the bowel.

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Drugs and gastrointestinal activity

Many of the drugs that are administered intraoperatively
can potentially affect intestinal activity.
The anticholinesterase neostigmine used to reverse neuromuscular block may increase bowel activity and intraluminal pressure and reduce colonic blood flow, hence
increasing the risk of anastomotic leak (Bell and Lewis,
1968; Whittaker, 1968). No large, well-controlled series
have assessed the detailed effect of neostigmine or the anticholinesterases atropine or glycopyrollate on the human
colon in clinical practice. It is frequently possible to avoid
the use of neostigmine in modern practice (Hunter, 1996).
Halothane depresses intestinal and colonic contractions
and antagonises the effect of morphine and neostigmine
on the bowel (Marshall et al, 1961). Diazepam depresses
gastrointestinal motility (Birnbaum et al, 1970) and
metoclopramide, although it generates contractions, may
prolong ileus because the contractions are uncoordinated
and non-propulsive (Jepsen et al, 1986).
Morphine increases the tone of the small and large
intestine but decreases motility. The effects can be antagonised experimentally with naloxone. It has been suggested
that in patients with diverticular disease morphine should
be avoided because of the risk of colonic spasm and diverticular perforation (Painter and Truelove, 1964a). It has
also been suggested that because of its spasmolytic effects
pethidine may be the analgesic of choice following intestinal anastomosis; on the other hand it may contribute to
postoperative ileus in view of its atropine-like action
(Painter and Truelove, 1964b; Ekbom et al, 1980).
Spinal and epidural anaesthesia increase motility in the
colon because blockade of the sympathetic nerves allows
the parasympathetic to act unopposed. Disruption of a
colonic anastomosis in the early postoperative period has
been attributed to the increased contractility associated
with extradural blockade (Bigler et al, 1985) but more
recent evidence contradicts this (Holte and Kehlet, 2001).
Colonic blood flow
Whittaker and colleagues (Whittaker, 1968; Whittaker
et al, 1970) concluded that the blood flow to the bowel was
the most important factor in the healing of an anastomosis and that a 10% reduction in blood volume from
haemorrhage markedly increased the risk of anastomotic
breakdown. Schrock et al (1973) found a high anastomotic
leakage rate when the blood pressure fell below 50 mmHg.
Blood viscosity is cited as being an important factor in
wound healing and there is a theoretical optimal haematocrit at which the balance between oxygen carriage and
viscosity maximises the oxygen delivery to the tissues: this
is about 11 g/dL, which corresponds to a haematocrit of
35% (Gruber, 1970).
Colonic perfusion is regulated extrinsically by the sympathetic and parasympathetic systems: intrinsically, arteriolar and precapillary tone are modulated by cellular
metabolites, and arteriolar smooth muscle contractility
responds to stretch, providing some myogenic autoregulation. There are thus many ways in which anaesthesia and
its effects can affect colonic blood flow.
Halothane decreases vascular resistance and increases
mesenteric blood flow. Enflurane produces little change but

isoflurane, surprisingly, was found to increase splanchnic

vascular resistance (Tverskoy et al, 1985). However, isoflurane can suppress the reflex vasoconstriction in the renal
and intestinal blood vessels in response to surgical stimulation, and to this end its effects were beneficial (Ostman
et al, 1986). All these effects of volatile agents are dose
dependent and motility returns to normal as the drug is
eliminated. Thus, volatile agents are unlikely to alter the
postoperative course by effects on gut motility, although
they may modify the effects of other drugs given during the
operation. Nitrous oxide diffuses into gas-containing viscera more rapidly than nitrogen diffuses out, with resultant distension of the bowel. This distension may hamper
abdominal wall closure, predispose to ileus and interfere
with colonic blood flow (Lewis, 1975); there are no hard
data to quantify these theoretical problems in patients.
If it is necessary to administer vasoactive agents there
is considerable potential for altering colonic blood flow.
Direct or indirect action on the splanchnic and lumbar
colonic nerves decreases blood flow by vasoconstriction.
Adrenaline and noradrenaline increase colonic vascular
resistance and decrease blood flow and oxygen uptake; isoprenaline increases colonic perfusion but appears to have
no effect on oxygen uptake. Vagal stimulation has little
effect on colonic blood flow, but activity in the parasympathetic pelvic nerves causes intense hyperaemia.
Spinal and epidural anaesthesia vasodilate the body
caudal to the height of the block. Blood flow to the bowel
reflects the balance between the degree of vasodilatation
and the reduction in systemic arterial perfusion pressure.
In dog models, a 22% increase in colonic blood flow has
been recorded with the onset of epidural block (Aitkenhead
et al, 1980). In humans, although retrospective studies
have suggested a reduction in anastomotic breakdown
with the use of spinal block, this has not been confirmed
by prospective studies (Worsley et al, 1988). Although
spinal block may well improve colonic blood flow, any
improvement may be negated by haemorrhage or the use
of vasoconstrictors.
In summary, there are therefore no definite conclusions
to be drawn that can at present recommend any one particular intraoperative anaesthetic technique as being superior to another, given that patients are well oxygenated and
hydrated.
Perioperative blood transfusion
Adequate perioperative fluid replacement is necessary to
maintain vital organ function. Blood transfusion may be
associated with many unwanted sequelae including infection and allergic reactions. Subsequent immunosuppression is well described, probably due to donor leucocytes
carrying foreign antigens and this may be associated with
increased tumour recurrence rate after colorectal surgery
(Wheatley and Veitch, 1997). To reduce this risk, leucocyte-depleted blood has been used, as have a variety of
methods to reduce the requirement for homologous blood
transfusion. There has also been a move, over the past few
years, towards accepting a lower perioperative haemoglobin level in otherwise fit patients. This may even improve
tissue perfusion, providing that the circulating fluid volume
is maintained.

Risk Management

Anaesthesia for minimally invasive surgery

Laparoscopic techniques for abdominal surgery offer a
number of advantages, including reduced postoperative
pain, low postoperative pulmonary dysfunction and a
quicker recovery. However, the effects of a pneumoperitoneum, changes in position and prolonged surgery may
have significant adverse effects, especially in patients with
pre-existing cardiorespiratory disease.
A steep Trendelenburg position will cause a cephalad
movement of the diaphragm leading to a reduced functional residual capacity, reduced lung volume and pulmonary compliance and possibly a deterioration in
ventilation/perfusion matching. The pneumoperitoneum
will exacerbate these changes. If carbon dioxide is used as
the insufflating gas, this will be absorbed systemically, leading to a progressive rise in carbon dioxide excretion which
usually plateaus after 20 minutes. This is an important
period for careful monitoring since intravascular carbon
dioxide can be fatal. A significant gas embolus is characterised by a sudden fall in expired carbon dioxide and
cardiovascular collapse. Monitoring with capnography
is mandatory as is good communication between
anaesthetist and surgeon.
The Trendelenburg position produces an increased
venous return and central venous pressure which may
produce deleterious effects in those with coronary artery
disease or ventricular dysfunction. Intra-abdominal insufflation is associated with a marked reduction in cardiac
output due to a diminution of venous return and increased
systemic vascular resistance. Splenic and mesenteric blood
flow may also be deleteriously affected. These side effects
are all increased if the laparoscopic procedure proves
difficult and is of long duration.
In addition, the anaesthetist may have to deal with
the other consequences of surgical complications such as
pneumothorax and vascular trauma (Brichant, 1995).

Postoperative care
All patients recovering from general or regional anaesthesia should be admitted to a properly staffed and equipped
recovery room until they are in a satisfactory condition to
return to the general ward. There should be adequate
provision of high-dependency beds for patients undergoing major surgery or for those with significant intercurrent
disease, thereby allowing appropriate analgesia and
physiological support postoperatively. The use of highdependency beds allows proper intensive therapy facilities
to be used only for those patients requiring a higher level
of respiratory or cardiovascular support.
The major effects of anaesthesia on pulmonary gas
exchange in the postoperative period depend upon the site
of surgery. In the operative and immediate postoperative
period the functional residual capacity (FRC) is reduced
with alveolar gas trapping and there is an increased rightto-left shunt. The cause is unknown but it can produce a
fall in PaO2 of up to 30 mmHg (4.0 kPa) when breathing
air compared with the preoperative level. It is easily corrected by giving 3040% oxygen through a facemask. After
the first hour or two most patients reverse these changes
and effectively return to their normal preoperative state.
However, when patients with previously healthy lungs

undergo abdominal surgery this reduction in oxygenation

continues for at least 48 hours and may extend for up to 5
days. This effect is worst with upper abdominal, thoracic
and paramedian incisions and least with lower abdominal
incisions. Factors known to exacerbate these effects are
wound pain (prevents deep breathing, can reduce vital
capacity by up to 50% and reduces expiratory force),
abdominal distension (splints the diaphragm), the supine
position (when the relationship of FRC to closing volume
is least favourable) and overtransfusion (tendency to pulmonary oedema).
All the above changes are intensified in patients with
poor preoperative lung function, cigarette smokers, the
obese and the aged. They are also the groups most at risk
from infection and segmental collapse secondary to sputum
retention.
Postoperative pain relief
Effective postoperative pain relief is important not only for
humanitarian reasons but may also confer other benefits:

Pain relief can aid rapid mobilisation, thus reducing the

complications of bed rest (deep vein thromboses and
pressure sores).
Pain may inhibit effective ventilation and expectoration
resulting in hypoxia and the development of chest infections. Good pain relief also facilitates effective physiotherapy.
Pain produces hypertension and tachycardia and inhibits
sleep. This can produce tiredness, irritability and myocardial ischaemia in susceptible persons.
There is also good evidence that effective pain relief
reduces the detrimental components of the metabolic
stress response to surgery.

There is a tremendous variability in individual requirements for postoperative analgesia. This is related to the site
of surgery, pharmacokinetic and pharmacodynamic variability, the psychological make-up of the patient and the
expectations of the ward staff. Regular recording of pain
postoperatively allows proper assessment and audit of the
problem and may, in itself, improve the administration of
analgesia (Gould et al, 1992). Recording may take the form
of a visual analogue scale or a simple scoring system. It is
preferable that the pain scores are recorded on the same
sheet as a sedation score and other routine postoperative
observations including respiratory rate, pulse and blood
pressure. Acute pain services are well established in many
hospitals and are instrumental in education, audit and
research and promoting safety.
The several ways in which postoperative pain can be
managed are described briefly below.
Oral analgesia

Oral analgesia for minor procedures may include paracetamol, codeine and tramadol. The latter is associated
with less constipation than codeine. Non-steroidal antiinflammatory drugs are useful for relieving the pain of
minor surgery and may also be used after major surgery
for their morphine sparing effect. Side-effects may include
renal dysfunction, bronchospasm and peptic ulceration.
Recent clinical guidelines on their use have been

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Chapter 3

Perioperative Care

published by the Royal College of Anaesthetists (Royal

College of Anaesthetists, 1998). Cyclo-oxygenase II
inhibitors may be associated with a reduction in some side
effects. Oral morphine is effective if gastrointestinal function is intact.
Intramuscular opioids

The administration of an intramuscular opioid drug on an

as required basis produces peaks and troughs of analgesia and provides poor control of pain. This can be improved
by with more frequent dosing guided by an algorithm
incorporating pain and sedation scoring. However, the
method obviously entails repeated painful injections.
Intravenous opioid infusions

These are best established with an intraoperative loading

dose and then continued into the postoperative period.
Properly managed they can be very effective and have
the advantage of being able to be titrated to individual
need by the nursing staff. The major danger is the risk of
serious respiratory depression occurring and respiratory
monitoring is mandatory. It is the view of many anaesthetists that this form of analgesia should not be used outside an intensive therapy unit, high-dependency unit or
other specialised environment.
Patient-controlled analgesia

The basis of patient-controlled analgesia (PCA) is that

patients are able to control how much analgesia they
receive, within the limits set by the prescribing doctor. To
set a PCA regimen it is necessary to decide several factors,
e.g. type of drug, size of bolus dose, lock-out interval,
background infusion rate (if any) and total dose permissible within a given time interval. PCA is usually used to
administer drugs intravenously but has also been used by
intramuscular, subcutaneous or extradural routes.
Several studies have shown that the use of PCA is associated with a lower total dose of drug and superior patient
satisfaction.
Caudal blocks

These have been described above and, using bupivacaine

on a single-shot basis, provide several hours of effective
analgesia for operations on the anus and perineum.
Spinal techniques

Only spinal opioids are relevant to postoperative pain control because local anaesthetics are short acting and spinal
blocks cannot be topped up. Spinal opioid receptors exist,
probably in the substantia gelatinosa, and their action is
thought to be presynaptic, reducing the release of substance P from the first-order pain neurons. Analgesia from
intrathecal morphine typically lasts for 24 hours and the
major danger is respiratory depression, which may not
occur maximally for several hours. Some of the complications of spinal anaesthesia have been given above in the
section on subarachnoid (spinal) block. Careful monitoring of respiration is essential after the administration of
spinal opioids. The side-effects of spinal opioids are similar
to those of epidural opioids.

Epidural techniques

Well-conducted epidural analgesia should provide the gold

standard for pain relief at rest and on movement. Other benefits may include a reduction in perioperative myocardial
ischaemia, attenuation of the stress and metabolic response,
improvement in pulmonary function and a reduction in
thromboembolic complications. Epidural analgesia allows
the avoidance of systemic opioids and a reduction in sympathetic activity. This should reduce the duration of postoperative ileus and improve bowel blood flow. Meta-analysis
has been disappointing in showing little improvement in
overall outcome with epidural analgesia and there has been
much discussion why this may be, including variation in
epidural technique, efficacy of epidurals in the studies and
end points of therapy (Ballantyne, 2004). There is evidence
to suggest that an improved outcome may be obtained if
used as part of a multimodal rehabilitation strategy including limited surgical injury, maintenance of normothermia,
early enteral nutrition and early post operative mobilisation
(Wilmore and Kehlet, 2001).
To cover the required dermatomes and to minimise
lower limb blockade a thoracic approach to the epidural
space is most appropriate. It is, however, more technically
challenging and carries a greater risk of accidental
neurological damage.
Most commonly, opioids or local anaesthetics are given
by the epidural route although other agents e.g. clonidine,
have been used. Drugs may be used as sole agents or in
combination. A mixture of a low concentration of a local
anaesthetic, e.g. bupivacaine 0.1%, and an opioid, e.g. fentanyl, given by continuous infusion will usually provide the
best analgesia and limit the hypotension caused by local
anaesthetic alone and the effect on gut motility produced
by epidural opioid alone. (Wheatley et al, 2001). The use
of local anaesthetic alone provides the best conditions for
a rapid return to normal gut motility (Holte and Kehlet,
2000). Drugs may also be delivered by PCA or bolus
methods.
Epidurals need to be managed aggressively by the acute
pain team to maintain efficacy. This may include early
catheter replacement if the block is inadequate.
Postoperative nausea and vomiting
Many patients consider nausea and vomiting to be the most
unpleasant aspect of their postoperative course and may,
for example, desist from using a patient-controlled analgesia pump to avoid this complication. There may also be
more serious effects, including wound dehiscence, bleeding, dehydration, electrolyte imbalance as well as economic
sequelae from increased recovery room stay and unanticipated admission after day surgery (Reynolds and Blogg,
1995). The reported incidence of postoperative nausea
and vomiting (PONV) is very variable but is increased in
females, non-smokers, those with a past history of PONV
or motion sickness and the administration of opiates. The
type of surgery is also important: abdominal and laparoscopic surgery are associated with a higher incidence.
Volatile anaesthetic agents may cause early PONV
whereas propofol may be mildly anti emetic. Avoidance of
opioid analgesia should be considered for those at risk from
PONV.

Risk Management

A variety of drugs is available for prophylaxis and treatment. These act at different receptor sites and a combination of agents may be considered appropriate in high risk
patients. Agents available include the phenothiazines (e.g.
prochlorperazine), the butyrophenones (e.g. droperidol),
antihistamines (e.g. cyclizine), 5-hydroxytryptamine antagonists (e.g. ondansetron) and dexamethasone. Significant
side effects may occur with some of these agents.
Metoclopramide has limited efficacy for PONV. There
is good evidence that acupuncture may also be a useful
treatment modality.

COLORECTAL SURGERY AND NUTRITION

Malnutrition
Malnutrition is common on admission to hospital (Corish
et al, 2004), particularly in elderly surgical patients
(Rosenthal, 2004) and is associated with adverse outcomes
in surgery. Windsor and Hill (1988) assessed weight loss in
102 patients before major surgery and assigned each patient
to one of three groups: group I (n = 43) were normal, group
II (n = 17) had weight loss greater than 10% but no clinical
evidence of physiologic impairment, and group III (n = 42)
had weight loss greater than 10% with clear evidence of dysfunction of two or more organ systems. The patients in
group III had significantly more postoperative complications
(P < 0.05), more septic complications (P < 0.02) including
a higher incidence of pneumonia (P < 0.05) and a longer
hospital stay (P < 0.05) than patients in each of the other
two groups. Colorectal patients with inflammatory bowel
disease and colorectal neoplasia are particularly at risk of
perioperative malnutrition. De la Hunt (1984) specifically
identified colorectal patients at high risk of postoperative
complications especially sepsis and breakdown of anastomoses and wounds. Using anthropometric measurements:
of 30 recorded major postoperative complications, 72% were
seen in patients with low body weight, 69% with low forearm muscle circumference, 55% with recent weight loss,
and 57% with serum albumin below 35 g/L.

Assessments
In the acute-care setting (Huckleberry, 2004), history of
weight loss from the patient, relatives or care-giver is the
basis of most nutritional assessments. As a rule of thumb,
patients weighing less than 70% of their ideal weight or
less than 80% of their usual weight are considered severely
malnourished. However, the accuracy of determining
weight loss by history alone has been questioned
(Jeejeebhoy, 2000): 33% of patients with weight loss being
missed and 25% of those with stable weight being wrongly
diagnosed as having lost weight. Aspects of physical examination may also be useful (Hammond, 1999) in assessing
nutritional status. Anthropometry includes triceps and
subscapular skinfold thicknesses, which provides an index
of body fat, and mid-arm muscle circumference, which
gives a measure of muscle mass. Although these measurements seem to be useful in population studies, their reliability in individual patients is less clear (Jeejeebhoy, 2000).
A valuable tool of bedside nutritional assessment is the
technique of subjective global assessment (SGA; Jeejeebhoy,
2000). The history used in the SGA determines:

Percentage of body weight lost in the previous 6 months:

mild (< 5%), moderate (510%), and severe (> 10%).
Dietary intake: normal or abnormal as judged by a change
in intake and whether the current diet is nutritionally adequate.
Presence of persistent gastrointestinal symptoms such as
anorexia, nausea, vomiting, diarrhoea, and abdominal
pain, which have occurred almost daily for at least
2 weeks, is recorded.
Functional capacity: defined as bedridden, suboptimally
active or full capacity.
Metabolic demands of the patients underlying disease
state: high-stress illnesses are burns, major trauma and
severe inflammation such as acute colitis; moderate-stress
diseases might be a mild infection or limited malignancy.

Physical examination includes assessing:

Loss of subcutaneous fat is measured in the triceps region

and the midaxillary line at the level of the lower ribs.
Muscle wasting in the temporal areas and in the deltoids
and quadriceps, as determined by loss of bulk and tone
detectable by palpation.
Presence of oedema in the ankle and sacral regions
and/or the presence of ascites.
Mucosal and cutaneous lesions are recorded, and the
colour and appearance of the patients hair.

The findings of the history and physical examination are

used to categorise patients as being well nourished, having
moderate or suspected malnutrition, or having severe
malnutrition (Table 3.28).
Malnutrition as measured by subjective global assessment is associated with postoperative complications after
major abdominal surgery (Sungurtekin et al, 2004). Gupta
et al (2005) examined the prognostic significance of SGA
in patients with advanced colorectal cancer. The prevalence
of malnutrition in this patient population, as determined
by SGA, was 52% (113/217). The median survival of
patients with SGA A was 12.8 months (95% CI 9.116.5),
those with SGA B was 8.8 months (95% CI 6.710.9) and
those with SGA C was 6 months (95% CI 3.98.1); the difference being statistically significant (P = 0.0013). In addition to being a clinically useful tool, SGA is a clinical
technique that can be rapidly taught to medical personnel
(Duerksen, 2002) (Table 3.29).
Visceral proteins
Low serum albumin correlates with an increased incidence of medical and surgical complications. Kudsk et al
(2003) performed a retrospective study of 526 surgical
patients who had preoperative serum albumin levels
measured and underwent elective oesophageal, gastric,
pancreaticoduodenal or colon surgery between 1992
and 1996 and did not receive preoperative nutrition.
Preoperative albumin correlated inversely with complications (Table 3.30), length of stay, postoperative stay, ICU
stay, mortality, and resumption of oral intake. Patients
undergoing oesophageal or pancreatic procedures sustained a significantly higher complication rate at most
albumin levels, whereas colonic surgery resulted in lower
complication rates at the same albumin levels.

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TABLE 3.28

CLASSIFICATION OF NUTRITION STATUS

Well nourished
No history of weight loss
No change in dietary intake
No physical findings
associated with
malnutrition
Improving findings of
malnutrition (recent
weight gain)

Moderately malnourished
History of decreased dietary intake
Weight loss (unintentional) of 5% to
10% of usual body weight
Mild signs of malnutrition on
physical examination:
Loss of subcutaneous fat
Muscle wasting

Severely malnourished
History of decreased dietary intake
Weight loss (unintentional) > 10% of usual body
weight
Severe signs of malnutrition on physical
examination:
Loss of subcutaneous fat
Muscle wasting

After Duerksen (2002).

TABLE 3.29 SUBJECTIVE GLOBAL ASSESSMENT OF MALNUTRITION

CORRELATED WITH IDEAL/USUAL BODY WEIGHT AND BMI
SGA
Malnutrition
Mild
Moderate
Severe

% ideal
body weight
8090%
7079%
< 70%

% usual
body weight
9095%
8089%
< 80%

BMI kg/m2
1718.5
1617
< 16

After Salvino et al (2004) and Huckleberry (2004).

BMI, body mass index.

TABLE 3.30 INCIDENCE OF MAJOR COMPLICATIONS BY PREOPERATIVE ALBUMIN LEVEL AND

SITE OF SURGERY
Albumin level
Site of complication
Oesophagus
Stomach
Pancreas
Colon
Total

n
59
140
106
221
526

17.5
17.622.5
22.627.5
27.632.5 32.637.5
1/1

2/4
5/11
6/13
3/4
3/6
4/16
8/27
6/33
1/1
3/4
8/11
8/17
6/32
2/7
6/14
4/19
7/40
9/54
7/13 (54%) 12/24 (50%) 18/50 (36%) 28/95 (29%) 27/132 (20%)

37.642.5
6/25
7/46
4/30
2/68
19/169 (11%)

> 42.5
1/5
2/8
1/11
0/19
4/43 (9%)

After Kudsk et al (2003).

Although albumin concentration correlates with outcomes it is not a good indicator of nutritional status per se
(Jeejeebhoy, 2000). This is because several processes control plasma albumin concentration, including the absolute
rate of albumin synthesis, the fractional catabolic rate
(FCR), albumin distribution between the vascular and
extravascular compartments, and exogenous loss of albumin. Thus the rate of albumin synthesis is affected by both
nutrition and inflammation, given that albumin is a negative acute-phase protein (Don and Kaysen, 2004).
Prealbumin has been proposed as a visceral protein that
is responsive to nutritional changes. However, it is also
influenced by several disease-related factors, making it
unreliable as an index of nutritional status in patients
(Jeejeebhoy, 2000).

Perioperative enteral nutrition

Delivery
For the large majority of hospital patients, enteral nutrition means hospital food. Unfortunately, eating in hospital
can be difficult for some patients. This can be attributed to
the disruption of sociocultural, psychological and physiological factors that occurs as a result of illness and/or hospitalisation (Holmes, 2003). For example, admission to
hospital may cause significant stress, markedly reducing
interest in food. Similarly, although it is known that eating
improves when some control is exerted over the diet,
patients can rarely influence either their food or times of
eating. There is an expectation that food will be poor and,
in practice, the daily expenditure (Table 3.31) on food and
drink for UK hospital patients is remarkably modest (Audit

Risk Management

TABLE 3.31 NET EXPENDITURE ON FOOD

AND BEVERAGES PER PATIENT DAY
Location of
Hospital Trust

Total net expenditure

per patient day

Outside London
Small Trust
Medium-sized Trust
Large Trust

6.56
5.91
5.46

London
7.64
From Audit Commission (2001).

Commission, 2001). Fulham (2004) has suggested that a

snack box should be made available to patients undergoing
colorectal and stoma surgery once oral intake is resumed
(containing yoghurt, bananas, digestive biscuits, cheese
and crackers). In addition, verbal and written dietary
advice should be provided for patients with new stomas,
those undergoing stoma reversal and those having resection
without stoma formation.
Formal oral nutritional supplementation can be an effective intervention in colorectal patients (Smedley et al,
2004). Keele et al (1997) randomised principally colorectal cancer surgical patients to receive either a normal ward
diet postoperatively, or the same diet supplemented with an
oral dietary supplement. During the inpatient phase,
patients treated with oral supplements had a significantly
improved nutritional intake and lost less weight (2.2 kg;
95% CI 0.9 kg) than control patients (4.2 kg; 95% CI 0.78
kg; P < 0.001). Supplemented patients maintained their
hand grip strength whereas control patients showed a
significant reduction in grip strength (P < 0.01). Subjective
levels of fatigue increased significantly above preoperative levels in control patients (P < 0.01) but not in the
supplemented group. Twelve patients in the control group
developed complications compared with four in the
supplemented group (P < 0.05). Thus, merely raising
nutritional intakes with oral dietary supplements or early
postoperative enteral feeding appears to be sufficient to
maintain immune and muscle function in patients
undergoing elective lower gastrointestinal surgery (Silk,
2003). In addition, enteral nutrition is associated with a
specific therapeutic effect in Crohns disease. Gassull et al
(2002) record that three meta-analyses of RCTs comparing steroids and enteral nutrition in the treatment of active
Crohns disease show that although steroids are more
effective, the overall remission rate by intention-to-treat
after enteral nutrition is 60%, substantially higher than
the placebo response in trials evaluating other drugs for
Crohns disease.
Short-term delivery systems for enteral nutrition include
nasogastric (NG; 14 to 16 French), nasoduodenal and
nasojejunal tubes (Nisim and Allins, 2005). These systems
avoid a surgical procedure but are probably only useful for
short-term (< 6 weeks) nutrition. The length of tube

required is gauged by measuring the distance from the nose

to an earlobe and then to the xiphoid process. Appropriate
placement of nasoenteric tubes can be confirmed by auscultation over the epigastrium or the left upper quadrant
of the abdomen while insufflating air (50 mL) down the
tube. However, this auscultation technique can be unreliable and a postinsertion X-ray should be taken to confirm
placement of the tube (Williams and Leslie, 2004; Nisim
and Allins, 2005). To minimise the risk of aspiration, the
head of the bed must be elevated to 30 to 45 degrees. The
nasoenteric tube should be flushed with water after being
used to administer medication.
The assumption that nasojejunal tubes are superior to
nasogastric feeding with regard to avoiding aspiration has
been challenged. Strong et al (1992) compared chest X rays
from 17 stomach-fed patients with 16 patients fed postpylorus. Chest radiographs met the criteria for aspiration
pneumonia in 31.3% of gastric and 40% of postpylorusfed patients (P = NS). Together, these data indicate that
complications from enterally fed patients are equally common whether the distal port of the feeding tube is in the
stomach or beyond the second portion of the duodenum.
Similarly, in a critical care setting Neumann and DeLegge
(2002) found no increase in aspiration and other adverse
outcomes when the nasogastric route was compared with
nasal-small-bowel feeding tubes. Moreover, patients fed in
the stomach received nutrition sooner from initial placement attempt (11.2 hours versus 27.0 hours) and with
fewer attempts (one versus two) than those fed in the small
bowel. Patients achieve feeding goals sooner (28.8 hours
versus 43.0 hours) with gastric feeding compared with
small-bowel feeding. Eatock et al (2005) also reported that
enteral nutrition of patients with acute pancreatitis was
cheaper and easier with nasogastric feeding compared to
nasojejunal feeding.
The goal of enteral feeding (Nisim and Allins, 2005)
is to approximate normal nutrient consumption in an
individual. As such, intermittent bolus feedings (1216
hours in each 24-hour period) are typically implemented.
The rate of administration is determined by infusing into
the stomach a volume of water that is equivalent to the
desired hourly feeding volume. This should be done gradually over 1 hour to avoid acute gastric distension, which
can lead to overestimation of the residual volume. At the
end of the hour, the feeding tube should be clamped for
30 minutes. The residual volume is then checked by
unclamping the feeding tube and aspirating any remaining fluid. One can initiate tube feedings if the residuals
are less than 50% of the infused volume.
Longer-term delivery systems (Culkin and Gabe, 2002;
Dormann and Huchzermeyer, 2002; Gopalan and Khanna,
2003; Nisim and Allins, 2005) include percutaneous endoscopic gastrostomy (Holmes, 2004), percutaneous endoscopic jejunostomy, needle catheter jejunostomy, operative
gastrostomy, which can be temporary (e.g. Stams technique) or permanent (e.g. Janeways technique) and open
or laparoscopic jejunostomy. Infection of the tube insertion
site can be a source of patient morbidity. MRSA infection
of gastrostomy and jejunostomy sites may be reduced by a
strategy consisting of screening, skin decontamination and
glycopeptide prophylaxis (Rao et al, 2004). Once these

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Chapter 3

Perioperative Care

tubes become colonised by MRSA, eradication is usually

only achieved either by removing the tube altogether or if
needed long term by replacement under vancomycin cover.
McClave and Chang (2003) provide an overview of
complications associated with enteric feeding devices
(Table 3.32).
Laparoscopic gastrostomy was compared with open gastrostomy insertion by Murayama et al (1995). Operative
time was significantly shorter in the laparoscopic gastrostomy group (38 7 min) than in the open gastrostomy
group (62 19; P < 0.0001. Major complication rate for
laparoscopic gastrostomy was 6% and for open gastrostomy
was 11%. The authors concluded that laparoscopic gastrostomy was a safe and effective alternative to open gastrostomy, particularly in patients unable to undergo upper
endoscopy or in patients undergoing a concomitant laparoscopic procedure. Hotokezaka et al (1996) reviewed laparoscopic jejunostomy in 32 patients. Laparoscopic insertion
was successfully completed in 28 patients but the procedure
was converted to an open operation in four cases. Three of
these four were among 14 patients undergoing the procedure who had a history of previous abdominal surgery.
Major complications were observed in seven patients,
including one reoperation and one death from aspiration
pneumonia. Tube feeding was accomplished in all patients
with progression to a full enteral feeding proceeded without interruption in 20 patients. There is a risk of faecal tube
feed peritonitis in malnourished patients who leak from the
junction between the enterotomy and abdominal wall.
Composition
The carbohydrate content of a given feeding formula is the
primary source of calories. Most formulas contain 1 to 2
kcal/L. Carbohydrates are also the major determinants of
a formulas osmolality, which typically varies from 280 to
100 mOsm/kg of H2O. Protein contents of common liquid
feeding formulas range from 35 to 40 g/L. Patients who
have conditions that result in impaired intestinal absorption (e.g. inflammatory bowel disease) often benefit from
formulas with enhanced absorption properties. Small peptides tend to be better absorbed by the intestinal mucosa

TABLE 3.32
DEVICES
Procedure

Specific

than amino acids, hence these patients often receive peptide-based formulas. Lipids provide a concentrated source
of calories in the form of long-chain triacylglycerols derived
from vegetable oils. They are high-energy compounds that
contain approximately three times the amount of calories
as carbohydrates (9 kcal/g versus 3.4 kcal/g, respectively).
Typically, the total lipid content in formulas is limited to
30% of the total volume. A host of enteral formulas exist.
Table 3.33 lists important features that can be used for the
selection and administration of enteral feeding products
(Lipman, 2004).
Immunonutrients are defined as nutrients that provide specific benefits to the immune system, and include
glutamine, arginine, long-chain n-3 polyunsaturated fatty
acids (PUFAs) and nucleotides (Moskovitz and Kim,
2004):

Glutamine is a precursor for the synthesis of other amino

acids, purines and pyrimidines. It serves as an important nutrient for many cell types, including small intestine enterocytes, colonocytes and fibroblasts. Muscle
is the chief supplier, containing 60% of the total, free glutamine in the body. Limiting the supply of glutamine to
the immune system results in reduced capability of the
host to fight infection.
Arginine is a precursor for the synthesis of nitric oxide. It
is a dietary non-essential amino acid. Arginine levels are
reduced in stress states as a result of inadequate endogenous synthesis. Supplementation with arginine has been
shown to have beneficial effects on the immune response
by improving the response of peripheral blood cells to
mitogen, enhancing natural killer cell activity, and
increasing lymphokine-activated natural killer cell
populations.
Eicosapentaenoic acid (EPA) and PUFAs enhance the production of prostaglandin E-3 and decrease the production
of prostaglandin E-2. EPA and PUFAs have a major impact
on the function of many components of the immune
system. PUFAs exert their effect on membrane lipid
composition, the binding of cytokines, the formation of
membrane-generated cellular signals, and effects on gene
expression.

COMPLICATIONS ASSOCIATED WITH ENTERIC FEEDING

Nasoeneteric tube
Epistaxis 1.84.7%
Aspiration 01.8%

Migration 12.516%
Dislodgement 2541%
Tube breakage 1120%
Tube occlusion 920%

PEG
Aspiration 0.31%
Haemorrhage 1%
Other viscous injury 0.51.8%
Transient pneumoperitoneum 4056%
Prolonged ileus 3%
Site infection 5.430%
Excessive leakage 12%
Buried bumper up to 21.8%
GI bleeding 0.61.2%
Inadvertent extubation 1.64.4%

After McClave and Chang (2003).

GI, gastrointestinal; PEG, percutaneous endoscopic gastrostomy.

Risk Management

TABLE 3.33

CONSIDERATIONS IN ENTERAL NUTRITION FORMULA COMPOSITION

Water
Sufficient
free water
(1 kcal/cc
formulas) vs
concentrated
formulas with
free water
removed

Origin
Blenderised
whole food
vs defined
nutrient
substrates

Macronutrient content
Intact protein vs amino
acids and/or peptides
Complex carbohydrates
vs simple sugars
Normal fat content
vs reduced fat
medium-chain
triglycerides
Lactose-free

Added substrates
Soluble fibre
Immune-enhancing
nutrients: omega-3
fatty acids, RNA,
arginine, glutamine
Modules of protein,
carbohydrate or fat
can be added before
administration to
increase protein or
energy content

Disease specific
Liver
Pulmonary
Renal
Diabetes
Critical care

From Lipman (2004).

Grimble (2005) describes a transcriptional focus as the

basis of immunonutrition. Thus oxidant molecules upregulate cytokines, other inflammatory mediators, adhesion
molecules and enzymes associated with antioxidant
defence through the activation of nuclear transcription
factors such as nuclear factor kappa B (NFB) and activator protein-1 (AP-1). Both antioxidants and the omega3 fatty acid, EPA, prevent NFB from activation, the
former substances by reducing oxidative stress in the cell
and the latter by stabilisation of the transcription factor
complex.
Heys et al (1999) conducted a meta-analysis of 11 RCTs
(published in peer-reviewed journals) evaluating the use of
enteral nutritional support supplemented with combinations of key nutrients versus standard enteral nutrition, in
a total of 1009 patients with a critical illness. The key
nutrients used in the various combinations were L-arginine,
L-glutamine, branched-chain amino acids, essential fatty
acids and RNA. Although there was no reduction in patient
death, the analysis did reveal:

Significant reduction in the overall OR for the risks of

developing major (pneumonia, intra-abdominal abscess,
major wound infections, septicaemia) infectious complications (OR 0.47; 95% CI 0.320.70).
Significant reduction in hospital stay for patients receiving targeted nutrition. This was a reduction of 2.5 days
(95% CI 4.01.0 days; chi square test for heterogeneity
4.73; P = NS).

A similar, more recent meta-analysis (Montejo et al, 2003)

examined randomised clinical trials of critically ill patients
treated with enteral nutrition comparing diets enriched
with pharmaconutrients with non enriched enteral diets.
Infectious complications and outcome variables (days on
mechanical ventilation, ICU and hospital length of stay and
mortality) were evaluated. Global results from 26 relevant
primary studies indicated that immunonutrition regimens
are associated with:

a reduction in infection rate: lower incidence of abdominal abscesses (OR 0.26; 95% CI 0.120.55; P = 0.005),
nosocomial pneumonia (OR 0.54; 95% CI 0.350.84;
P = 0.007) and bacteraemia (OR 0.45; 95% CI
0.350.84; P = 0.0002)

a reduction in time on mechanical ventilation (mean 2.25

days; 95% CI 0.53.9; P = 0.009), ICU length of stay
(mean reduction of 1.6 days, CI: 1.9-1.2) (P < 0.0001)
and hospital length of stay (mean reduction of 3.4 days;
95% CI 4.02.7; P < 0.0001)
no effect on mortality (OR 1.10; 95% CI 0.851.42;
P = 0.5).

On this basis, Montejo et al (2003) concluded that the evidence supported a grade B recommendation for the use of
immunonutrient enteral feed in ICU patients.
Garcia-de-Lorenzo et al (2003) described glutamineenriched diets as being associated with good overall tolerance,
improvement of immunologic aspects in multiple trauma
patients, cost reduction in critically ill patients and improvement of mucositis in postchemotherapy patients (grade B
recommendations). However, several studies reviewed by
Heyland and Samis (2003), with the exception of Galban
et al (2000), indicated that septic critical care patients randomised to immunonutrition fared less well than patients
receiving standard enteral nutrition or parenteral nutrition (Table 3.34). Thus, Bertolini et al (2003) studied 237
patients randomised by 33 ICUs between November 1999
and April 2001, 39 of whom had severe sepsis. Of these 39
patients with severe sepsis, 21 were randomised to receive
either TPN (59% carbohydrate, 23% fat, 18% protein,
1.2 kcal/mL) and 18 were randomised to an enteral nutrition formula that included L-arginine, omega-3 fatty acids,
vitamin E, beta carotene, zinc and selenium (55% carbohydrate, 25% fat, 21% protein, 1.3 kcal/mL). The ICU mortality of the group receiving the enteral immunonutrients
(44%) was significantly higher than the group assigned
parenteral nutrition (14%). Heyland and Samis (2003)
speculate that the immune-modulating nutrient (or combination of nutrients) responsible for the excess harm
observed, in septic patients in these studies is probably arginine. Arginine supplementation is capable of promoting an
increase in nitric oxide production, which may have
an adverse effect on critically ill patients with sepsis.
Heyland and Samis (2003) therefore recommend more
study of arginine supplementation before it is routinely
incorporated into immunonutrient regimens.
Kieft et al (2005) conducted the largest randomised,
controlled trial of immunonutrition in a general ICU

119

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TABLE 3.34

IMMUNONUTRIENTS AND MORTALITY OF SEPTIC PATIENTS IN CRITICAL CARE

Bower et al, 1995

Dent et al, 2003
Galban et al, 2000
Bertolini et al, 2003
(severe sepsis
subgroup)

Control group
4/45 (8.9%),
8/83 (9.6%)

Experimental
11/44 (25%)
20/87 (23%)

P value
0.051
0.03

28/87 (32.2%)
3/21 (14.3%)

17/89 (19.1%0
8/18 (44.4%)

0.05
0.039

Impact
L-arginine, omega-3 fatty acids,
vitamins A and E, beta carotene
Impact
L-arginine, omega-3 fatty acids, vitamin E,
beta carotene, zinc, selenium

After Heyland and Samis (2003).

population. The control group comprised 140 surgical, 16

trauma and 83 medical patients; the immunonutrition
group was composed of 113, 23 and 95 patients, respectively.
The study formula (immunonutrition) was a high-protein
enteral tube feed enriched with glutamine, arginine, 3-FA,
antioxidants and a mixture of fibres (Stresson Multi Fibre,
Nutricia, the Netherlands). The control feed was an
isocaloric enteral formula to prevent the groups receiving
different amounts of energy. Results of the intention-totreat analysis in control versus immunonutrition were:
median ICU length of stay in days, 8.0 (IQR 5.016.0)
versus 7.0 (4.014.0); median hospital length of stay in
days, 20.0 (IQR 10.034.0) versus 20.0 (10.035.0);
median days of ventilation, 6.0 (IQR 3.012.0) versus 6.0
(IQR 3.012.0); ICU mortality, 26.8% versus 28.2%; inhospital mortality, 36.4% versus 38.5%; infectious
complications, 41.7% versus 43.0%. Thus, immunonutrition has no beneficial effect on clinical outcome parameters
in the general ICU population. Heyland and Dhaliwal
(2005) concluded that the current approach to defining
those key nutrients that may have positive effects in critically
ill patients is not working. A new paradigm should focus
on single nutrients dissociated from nutrition, tested in
homogenous patient populations in large, rigorously
designed randomised clinical trials.

Perioperative parenteral nutrition

The Veterans Affairs Total Parenteral Nutrition Cooperative
Study Group (1991) studied 395 malnourished patients
who required laparotomy or non-cardiac thoracotomy and
randomly assigned them to receive either TPN for 715
days before surgery and 3 days afterward (the TPN group)
or no perioperative TPN (the control group). The patients
were monitored for complications for 90 days after surgery.
Major complications during the first 30 days after surgery
in the two groups were similar (TPN group 25.5%; control
group 24.6%), as were the overall 90-day mortality rates
(13.4% and 10.5%, respectively). Although the TPN group
had more infectious complications than in the controls
(14.1 versus 6.4%; P = 0.01; relative risk, 2.20; 95% CI,
1.194.05), this increase was confined to patients categorised as either borderline or mildly malnourished,
according to SGA or an objective nutritional assessment.
By contrast, severely malnourished patients who received
TPN had fewer non-infectious complications than controls
(5 versus 43%; P = 0.03; relative risk, 0.12; 95% CI,
0.020.91), with no concomitant increase in infectious

complications. The authors concluded that the use of preoperative TPN should be limited to patients who are
severely malnourished unless there are other specific
indications.
Heyland et al (2001) conducted a meta-analysis of 27
papers that met their inclusion criteria. Overall, 2907
patients were randomised to comparisons of TPN against
standard care (oral diet or intravenous dextrose solution).
Aggregation of the results of these trials showed no effect
on mortality (RR = 0.97; 95% CI 0.751.24). However,
TPN was associated with a reduction in complication rates
(RR = 0.081; 95% CI 0.651.01, P = 0.06). Comparison
was made between trials that only included malnourished
patients with the other available trials. TPN was again not
associated with any difference in mortality in either studies
of malnourished or normally nourished patients. However,
TPN was associated with a significant reduction in complication rates in the trials that contained overtly malnourished patients (RR = 0.52; 95% CI 0.300.91). The authors
(Heyland et al, 2001) concluded that although methodology and year of publication might influence the metaanalysis findings, TPN appears to reduce the complication
rate in surgical patients but not the death rate of this group.
Nehra et al (1999) described their indications for parenteral nutrition in 100 consecutive patients. Characteristics
of this patient population included mean weight (118
29% of ideal), body mass index (25 6 kg/m2) and serum
albumin (28 7 g/L). The most common specific reasons
identified for initiating TPN rather than enteral nutrition
were ileus (25%), an underlying acidbase or electrolyte/
mineral disorder requiring correction (13%) and the convenience of TPN because a central venous catheter was in
place (12%). Jones (2003) describes three clinical patterns
of intestinal failure which may require parenteral support:

Type 1: short-term intestinal failure as after abdominal

surgery when intestinal failure is self limiting.
Type 2: intestinal failure in severely-ill patients with major
resections of bowel and septic, metabolic and nutritional
complications requiring complex multidisciplinary intervention with metabolic and nutritional support to permit
recovery.
Type 3: chronic intestinal failure requiring long-term
nutritional support.

In most colorectal surgical practice parenteral support is

seen most commonly in type 1 patients and occasionally
in type 2 patients.

Risk Management

Complications of parenteral nutrition

Bloodstream infections are a common complication of
implanted venous access catheters. This is a troublesome
complication of short term total parenteral nutrition (TPN)
which can be fatal unless promptly treated. However, the
sepsis and lack of venous access from repeatedly changing
venous access catheters is the issue which determines life
expectancy in home parenteral nutrition (HPN). Tay et al
(2002) audited 50 patients in a surgical intensive care unit
and found that hyperglycaemia and line sepsis increased
with duration of TPN use. Moore et al (2004), in a retrospective survey of home parenteral nutrition patients,
describe a higher catheter infection rate with PICC lines
(458 per 100 catheter days) than with central venous
catheters (285 per 100 catheter days; P < 0.01). Surveys
of hospital-acquired bacteraemias and septicaemias in the
US have shown that during 19869, coagulase-negative
staphylococci, followed by Staph. aureus, were the most frequently reported causes of bloodstream infections,
accounting for 27% and 16%, respectively, but that pooled
data from 1992 to 1999 indicate that coagulase-negative
staphylococci, followed by enterococci, are now the most
frequently isolated causes of hospital-acquired bloodstream
infections (OGrady et al, 2002). The authors recommend
that strategies to reduce central-line sepsis might include:

educating and training health-care providers who insert

and maintain catheters
using maximal sterile barrier precautions during central
venous catheter insertion
using a 2% chlorhexidine preparation for skin antisepsis
avoiding routine replacement of central venous catheters
as a strategy to prevent infection.

Endocarditis is a particularly feared complication of central-line access and may require repeated echocardiography (Leinhardt et al, 1992) to confirm the diagnosis.
Fungal as well as bacterial infection may be implicated in
the valvular lesions (Schelenz and Gransden, 2003).
Sutton et al (2005) introduced a clinical nurse specialist to maintain protocol standards for parenteral nutrition
venous catheters. The protocols included care of the exit
site (exit site from the subcutaneous tunnel), sprayed with
Betadine Powder Spray (Seton Healthcare plc, UK), dressed
with Mepore (Smith and Nephew plc, UK) and covered
with an Opsite dressing (Smith and Nephew plc, UK) and
the use of designated nursing staff to commence TPN infusions. Designated nurses were required to attend a study
day and pass a practical assessment dealing with aseptic

procedures and TPN catheters. This innovation both

reduced the infection rate of central venous catheters
(Table 3.35) and paid for the cost of employing the clinical
nurse specialist by savings in wasted central venous
catheters, TPN and operating time.
Hepatobiliary dysfunction (Porayko, 1998) is associated
with the use of TPN occurring in up to 90% of patients on
long-term therapy. Luman and Shaffer (2002) described 51
patients (47.7%) with deranged liver function tests (LFT).
The abnormality in LFT was transient in nine patients. For
the other 42 patients (39%), abnormalities in LFT remained
stable for median duration of follow-up of 18.5 (range
3180) months. No patients developed decompensated liver
disease. On univariate analysis, length of small bowel of less
than 100 cm, a higher total caloric intake from HPN (home
parenteral nutrition) (mean 1117 486 kcal against 907
576 kcal, P < 0.05), and higher daily caloric intake from
HPN in relation to calculated daily energy requirement
(70 32% against 57 36%) were noted to be significantly
associated with deranged LFT. However, on multivariate
analysis, length of small bowel of less than 100 cm was the
only significant variable for deranged LFT.

Instituting surgical nutrition

There are three basic steps in providing perioperative
surgical nutrition:
1. Does the patient require nutritional support?
2. Which route(s)enteral or parenteralshould be
used?
3. Are the goals of nutritional support being achieved?
Malnourished patients are at greater risk for perioperative
and postoperative morbidity and mortality than wellnourished patients (Salvino et al, 2004). Preoperative
nutritional support should be considered for severely malnourished patients if their elective surgery can be delayed
for this period of time. Postoperatively, nutritional support
should be considered if it is anticipated that a patient will
be unable to eat within 7 to 10 days of surgery (Salvino
et al, 2004).
If perioperative nutritional support is required, which
is the best routeenteral or parenteral? The following
recommendations are based on ASPEN guidelines:

Moderately to severely malnourished patients scheduled

for major gastrointestinal surgery should receive 714
days of preoperative nutritional support if surgery can be
safely postponed.

TABLE 3.35 CATHETER-RELATED SEPSIS BEFORE (YEAR 0) AND AFTER INTRODUCTION OF

NUTRITION VIA CENTRAL VENOUS CATHETER IN PATIENTS ON HPN

Definite sepsis (%)

Probable sepsis (%)
Possible sepsis (%)

Year 0
(n = 56)
5.2

Year 1
(n = 54)
3.7
9.2
5.5

After Sutton et al (2005). HPN, Home parenteral nutrition.

Year 2
(n = 49)
2
4
4

Year 3
(n = 34)
2.9
0
0

Year 4
(n = 40)
2.3
0
0

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Parenteral nutrition should not be routinely prescribed

in the immediate postoperative period for patients
undergoing major gastrointestinal surgery.
Postoperative nutritional support is warranted if inadequate oral nutrition is anticipated for 710 days.

Heyland et al (2003) carried out a systematic analysis of

controlled clinical trials of nutrition in ICU patients. The
major findings of the analysis were:

Increased infectious complications for parenteral nutrition reported in six trials for which the relative risk for
enteral nutrition was 0.61. By contrast, there was no
significant difference in mortality or in length of stay.
Early enteral nutrition showed a trend toward reduced
mortality or infectious complications without statistical
significance.
Arginine supplementation in enteral nutrition did not
influence mortality or infections.
Glutamine supplementation resulted in heterogeneous
findings with reduced complications in some, but not
other, studies.
Enteral nutrition in the semirecumbent position significantly reduced the incidence of pneumonia in one
study.

The findings of reduced infectious complications with

enteral nutrition but no advantage in overall patient
mortality have been repeatedly reported in other systematic
comparisons. Braunschweig et al (2001) systematically
reviewed the results of prospective randomised clinical
trials to examine the relations among the nutrition interventions, complications and mortality rates. Aggregated
results from 27 studies involving 1828 patients showed a
significantly lower relative risk of infection with tube feeding (0.64; 95% CI 0.540.76) and standard care (0.77;
95% CI 0.650.91). However, in studies in which participants had high rates of protein-energy malnutrition, there
was a significantly higher risk of mortality (3.0; 95% CI
10.98.56) and a trend towards a higher risk of infection
with standard care than with parenteral nutrition (1.17;
95% CI 0.881.56). Gramlich et al (2004), from a metaanalysis of 13 studies, found that the use of enteral nutrition as opposed to parenteral nutrition was associated with
a significant decrease in infectious complications (RR =
0.64; 95% CI = 0.470.87; P = 0.004) but made no difference to mortality rate (RR = 1.08; 95% CI = 0.701.65;
P = 0.7). Peter et al (2005) examined 30 RCTs (10 medical,
11 surgical, 9 trauma) to compare the impact of early
enteral nutrition with parenteral nutrition on patient
outcomes. There was no differential treatment effect
of nutrition type on hospital mortality for all patients
(0.6%; P = 0.4) and subgroups. Parenteral nutrition was
associated with increases in infective complications (7.9%;
P = 0.001), catheter-related bloodstream infections (3.5%;
P = 0.003), non-infective complications (4.9%; P = 0.04)
and hospital LOS (1.2 days; P = 0.004). There was no
effect of nutrition type on technical complications (4.1%;
P = 0.2). Enteral nutrition was associated with a significant increase in diarrhoeal episodes (8.7%; P = 0.001).
If enteral nutrition is associated with no improvement
in mortality but is associated with a reduced rate of infec-

tious complications, does it have any drawbacks? The major

drawback of enteral nutrition in a critical-care population
is that the nutritional support can be inadequate. One
study of patients in a multidisciplinary ICU population
revealed that only 56% of goal caloric requirements were
met by enteral nutrition (Sigalet et al, 2004). Underfeeding
has been ascribed to gut dysfunction and elective cessation
of enteric feeding. Moreover, there does not appear to be
any advantage to combining enteral and parenteral nutrition in critically ill patients who are not malnourished and
have an intact gastrointestinal tract. Dhaliwal et al (2004)
examined studies of enteral nutrition alone against combinations of enteral and parenteral nutrition. When the
five identified studies were aggregated, meta-analysis
showed that the use of combination enteral and parenteral
nutrition had no effect on mortality (RR 1.27; 95% CI
0.821.94; P = 0.3).
In essence, there is no dichotomy in the use of parenteral or enteral nutrition. Although parenteral nutrition
is associated with more septic complications, it does provide a reliable means of delivering protein, energy, electrolytes and vitamins (Sigalet et al, 2004). Moreover,
parenteral nutrition has been shown to be associated with
improved survival in malnourished surgical patients when
compared to standard care.
The composition of all nutritional support is aimed at
delivering the correct requirements of water, electrolytes,
calories (carbohydrate and fat), protein, vitamins and
micronutrients. Total energy requirement is usually delivered as a mixture of glucose and lipid in a ratio of 60 : 40.
However, significant glucose intolerance or the requirement for fat free parenteral nutrition would need to be
factored into the individual patients regimen.
A patients energy requirements (basal metabolic rate;
BMR) can be estimated from equations such as the
Schofield or HarrisBenedict equation (Bauer et al, 2004)
(Table 3.36). In turn, the estimated BMR can be increased
by a stress factor associated with the degree of systemic
insultperhaps 520% by uncomplicated surgery and
2540% in complicated surgery using published nomograms (Reeves and Capra, 2003). However, among stress
factor estimates identified, including the Elia nomogram,
the evidence base for the estimates is less than robust.
The accuracy and agreement of estimated BMR is also
far from perfect (Bauer et al, 2004). McClave et al (1998)
found that, compared with indirect calorimetery measured
resting energy expenditure, nutritional regimens based on
the HarrisBenedict equation meant that underfeeding and
overfeeding were common, with only 25% of patients
receiving calories within 10% of required needs. The respiratory quotient (RQ = VCO2/VO2) has been proposed as
a test to determine the adequacy of caloric support.
Underfeeding, which promotes use of endogenous fat
stores, should cause decreases in the RQ, whereas overfeeding, which results in lipogenesis, should cause increases
in the RQ. However, McClave et al (2003) concluded from
a study of 263 enterally fed, mechanically ventilated
patients that although changes in the overall and non-protein RQ correlate to percentage calories provided/required,
low sensitivity and specificity limit its efficacy as an indicator of over- or underfeeding. In our experience, the

Risk Management

TABLE 3.36

ESTIMATION OF BASAL METABOLIC RATE

Equation
Harris and Benedict
Schofield

Subset of subjects
Males
Females
Males, 3060 years
Females, 3060 years
Males, over 60 years
Females, over 60 years

Formula
BMR (kJ/day) = (57.5 W) + (20.9 H) (28.3 A) + 278
BMR (kJ/day) = (40.0 W) + (7.7 H) (19.6 A) + 2741
BMR (MJ/day) = (0.048 W) + 3.653
BMR (MJ/day) = (0.034 W) + 3.538
BMR (MJ/day) = (0.049 W) + 2.459
BMR (MJ/day) = (0.038 W) + 2.755

From Bauer et al (2004).

BMR, basal metabolic rate.

typical surgical patient will require a 1800 kcal regimen

with an average daily requirement of 25 kcal/kg/day.
Excess calories should be avoided as they can adversely
affect liver function and lead to increased CO2 production.
For 95% of the normal population consuming an adequate energy intake, 0.8 g of protein/kg body weight is
adequate (Bistrian and Babineau, 1998). Surgical insult or
disease leads to protein malnutrition by inducing anorexia,
motor inactivity, protein anabolic inefficiency and an
increase in protein catabolism. Greater amounts of protein
than the recommended dietary allowance are required to
achieve protein sparing with increasing severity of the systemic inflammatory response syndrome, but further protein sparing is difficult to achieve once 1.5 g of protein/kg
body weight is provided. This situation invariably leads to
net protein loss early in the illness of most critically ill
patients (Bistrian and Babineau, 1998). Therefore, most
protein replacement regimens consist of 1.22.0 g/kg/day
(Huckleberry, 2004; Salvino et al, 2004). Protein provided
in excess of this amount is converted to urea.

ENHANCED RECOVERY AFTER

COLORECTAL SURGERY
One of the major benefits of laparoscopic colorectal surgery has been the realisation that the time honoured practice of postoperative starvation, morphine analgesia,
delayed ambulation inhibits the speed of recovery following both open and minimal access colorectal surgery.
Furthermore delayed feeding does not protect against anastomotic breakdown. The need for minimal analgesic
requirements and rapid recovery in laparoscopic surgery
has influenced open surgical practice and the development
of enhanced recovery policies (Wind et al, 2006). A group
of 60 consecutive patients scheduled for elective colonic
resection (excluding planned low anterior resection and
rectum extirpation, and patients undergoing surgery for
inflammatory bowel disease) were studied in the context of
an accelerated rehabilitation program by Basse et al
(2000). Features of the study design included:

Patient informed by the research team of a planned

48-hour postoperative hospital stay.
No premedication administered.
Thoracic epidural catheter inserted at T6T7 for right
hemicolectomy and at T8T10 for left-sided and sigmoid
resection. After surgery, continuous epidural analgesia
with bupivacaine and morphine maintained for 48 hours.

Right-sided hemicolectomy performed with a horizontal

incision 23 cm above the umbilicus, resection of the
transverse colon with a transverse incision cephalad to
the umbilicus, and left-sided hemicolectomy and sigmoid
resection with a curved incision in the left iliac fossa
extended up toward the curvature when necessary. All
anastomoses hand-sewn.
Gastrointestinal tubes not used.

Postoperative mobilisation and oral intake followed a welldefined nursing care program (Table 3.37).
The colonic resections (Basse et al, 2000) included 23
right-sided hemicolectomies, two resections of the transverse colon, 34 sigmoid resections or left hemicolectomies
and one subtotal colectomy. Median duration of surgery
was 120 minutes (range 70360). Median intraoperative
blood loss was 100 mL (range 502450 mL). Underlying
colonic disease was cancer in 42 patients (Dukes A in
four patients, Dukes B in 22, Dukes C in 11 and Dukes
D in five), lymphoma in one patient and benign colonic
diseases in 17 patients. Overall, normal gastrointestinal
function (defecation) occurred within 48 hours in 57
patients and the median hospital stay was 2 days. There
were no cardiopulmonary complications. The readmission rate was 15%, including two patients with anastomotic dehiscence (one treated conservatively, one with
colostomy); other readmissions required only short-term
observation.
In a similar study, Delaney et al (2001) subjected 60 consecutive patients [median age 44.5 (range 1370) years]
undergoing major procedures to a fast track protocol (early
diet and early ambulation; defined discharge criteria) over
a 6-week period. Nasogastric tubes and epidural anaesthesia were not used. Patients participated in a protocol of early
diet and early ambulation, and were discharged after meeting defined criteria. Fifty-eight patients (97%) were deemed
suitable for the fast track approach at the time of surgery
and stayed for a mean (S.D.) of 4.3 (1.6) days after operation. Three patients (5%) required a nasogastric tube for
vomiting. No readmissions were directly attributable to fast
track failure, although four patients (7%) were readmitted
within 30 days of operation for other reasons. Eight poorly
compliant patients stayed for 5.1 (1.1) days (P = 0.02
versus compliant patients).
A comparison of outcomes after colonic resection and
conventional care with fast-track multimodal rehabilitation was carried out by Basse et al (2004). However, the

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TABLE 3.37 NURSING CARE PROGRAMME

AND GOALS AFTER ELECTIVE COLONIC
RESECTION USING ENHANCED RECOVERY
Before surgery
Repeat information about perioperative course
previously given in the outpatient clinic. Discuss
with family the 2-day postoperative program. Fluid
nutrition including four protein drinks for 3 days.
Laxatives and bowel cleansing
After surgery
Day of surgery 024 hours
Mobilised: 2 hours, initiated 6 hours postoperatively
Drinking: 1000 mL including 2 protein drinks
Oral paracetamol 2 g q12 oral magnesium 1 g q12
and cisapride 20 mg q 12 (repeated during
subsequent days)
Additional bupivacaine, ibuprofen and opioid (in that
order) only for breakthrough pain
Normal food allowed
Postoperative day 1 (2448 hours)
Urinary catheter removed in the morning
Mobilisation 8 hours
Normal food and oral fluid > 2000 mL, including four
protein drinks
Plan discharge
Postoperative day 2 (48+ hours)
Epidural catheter removed in the morning
Oral ibuprofen 600 mg q 8 hours
Full mobilisation and normal oral intake
Stop cisapride, continue magnesium for 1 week
unless diarrhoea present
Discharge after lunch (48 hours postoperatively)
Postoperative day 8
Check-up in outpatient clinic
Suture removal and further treatment depending on
histology
Postoperative day 30
Check-up in outpatient clinic

two populations compared were treated in separate hospitals: 130 consecutive patients receiving conventional
care (group 1) in one hospital were compared with 130
consecutive patients receiving multimodal, fast-track
rehabilitation (group 2) in another hospital. Median age
was 74 years (group 1) and 72 years (group 2) and the
ASA score was significantly higher in group 2 (P < 0.05).
Defecation occurred on day 4.5 in group 1 and day 2 in
group 2 (P < 0.05). Median hospital stay was 8 days in
group 1 and 2 days in group 2 (P < 0.05). The overall
complication rate (35 patients) was lower in group 2
(P < 0.05), especially cardiopulmonary complications
(five patients; P < 0.01). Readmission was necessary in
12% of cases in group 1 and 20% in group 2 (P > 0.05)
(Basse et al, 2004).
Nygren et al (2005) performed a comparative study of
outcomes from four European units practising conven-

tional colorectal surgery with the reference fast-track

unit in Denmark. The study populations consisted of
451 consecutive patients from the conventional units
(Sweden, n = 109; UK, n = 87; Netherlands, n = 76,
Norway, n = 61) and 118 from the Danish centre. Based
on the P-POSSUM scores, the case mix was similar
between centres. There were no differences in morbidity
or 30-day mortality between the different centres. The
median length of stay was 2 days in Denmark and 79
days in the other centres (P < 0.05). The readmission rate
was 22% in Denmark and 216% in the other centres (P
< 0.05). Thus, when compared with traditional care, fasttrack perioperative care is associated both with a reduced
length of hospital stay but also with a higher readmission
rate (Table 3.38).
A small, randomised comparison between conventional
care (n = 11) and a 10-point optimisation programme
(n = 14) was reported by Anderson et al (2003) for patients
undergoing elective right or left hemicolectomy. In this
comparison the optimisation programme was associated
with maintained grip strength, earlier mobilisation (46 versus 69 hours; P = 0.043) and significantly lower pain and
fatigue scores. Patients in the optimisation group tolerated
a regular hospital diet significantly earlier than controls
(48 versus 76 hours; P < 0.001). In addition, the optimisation programme significantly reduced the median length
of hospital stay (3 versus 7 days; P = 0.002) (Anderson
et al, 2003).
Zutshi et al (2005) recently compared the utility of thoracic epidural anaesthesia with PCA in patients who had
laparotomy colonic resection and were then managed on
a fast track protocol. There was no difference in length of
stay (5.8 versus 6.2 days, thoracic epidural versus PCA,
P = 0.55), total length of stay (including readmissions),
pain scores, quality of life, complications or hospital costs
at any time point. They concluded that thoracic epidural
offers no advantage over PCA for patients undergoing
major intestinal resections who are on a fast-track postoperative care plan. Patients undergoing ileocolic resection for Crohns disease appear to do well on fast-track
protocols: epidural analgesia, enforced postoperative oral
nutrition and mobilisation with a scheduled stay of 2 days
(Andersen and Kehlet, 2005). Following 32 consecutive
ileocolic resections for Crohns disease in 29 patients, the
median time to defecation was 2.5 days and postoperative
hospital stay was 3 days. During a 30-day postoperative
follow-up there was two readmissions, one for mechanical
bowel obstruction (9 days) and one because of fever and
vomiting (6 days). Wind and others (2006) compared 6
studies using fast track surgery compared with conventional surgery, 3 of which were randomised studies. Fast
track was safe, shortened hospital stay and readmission
rates were not increased. Despite these results King and
others (2006) found that these advantages did not influence quality of life or health care economic outcomes.
For patients undergoing laparoscopic sigmoid colectomy, Raue et al (2004) found that a fast-track protocol
(epidural analgesia, early oral feeding and enforced
mobilisation) shortened the time to patient discharge.
Comparisons were made after laparoscopic sigmoid
resection between 29 standard-care patients (19 men and

Risk Management

TABLE 3.38 COMPARATIVE OUTCOMES OF FAST TRACK IN DENMARK COMPARED WITH

CONVENTIONAL PROGRAMMES IN EUROPE FOR COLORECTAL SURGERY
n
Mortality: n (%)
Readmissions: n (%)
Reoperations: n (%)
Length of stay in hospital: median (IQR)

Total
451
10 (2)
49 (11)
33 (7)

DK
118
6 (5)
26 (22)
8 (7)
2 (1)

NL
76
2 (3)
6 (8)*
7 (9)
8 (6)*

NO
61
1 (2)
10 (16)
8 (13)
7 (3)*

UK
87
1 (1)
2 (2)*
3 (3)
9 (6)*

SE
109
0 (0)
5 (5)*
7 (6)
7 (5)*

After Nygren et al (2005)

DK, Denmark; LOS, NL, Netherlands; NO, Norway; SE, Sweden; UK, United Kingdom.
*P < 0.05 versus DK.
IQR, interquartile range.

10 women) and 23 fast-track patients (15 men and 8

women). On the first postoperative day, pulmonary
function was improved (P = 0.01) in fast-track patients.
Oral feeding was achieved earlier (P < 0.01) and defecation occurred earlier (P < 0.01) in the fast-track group.
Fast-track laparoscopic sigmoidectomy patients were
discharged on day 4 (range 36 days) and standard-care
patients on day 7 (range 414 days) (P < 0.001).
All the elements of enhanced recovery after surgery
(Figure 3.11) have been the subject of a consensus from The
European Society of Clinical Nutrition and Metabolism
(ESPEN) special interest group on management of patients
undergoing colonic surgery (Fearon et al, 2005).
In all, the Consensus Group (Fearon et al, 2005) makes
20 recommendations as to perioperative care in promoting enhanced patient recovery:

Consensus 1: a patient should receive oral and written

preadmission information describing what will happen
during their hospital stay, what they have to expect, and
what their role is in their recovery.

Audit of compliance/
outcomes
Perioperative
oral nutrition

Consensus 2: patients undergoing colonic resection should

not receive routine oral bowel preparation. However,
bowel preparation may be essential in selected patients
who require intraoperative colonoscopy.
Consensus 3: patients should only be fasted for liquids for
2 hours and for solids for 6 hours preoperatively. Patients
should receive oral preoperative fluids and carbohydrate
loading.
Consensus 4: patients should not receive preanaesthetic
anxioloytic or analgesic medication.
Consensus 5: patients should receive antithrombotic
prophylaxis according to the local peer-reviewed protocol.
Consensus 6: patients should receive single-dose antibiotic
prophylaxis against both aerobic and anaerobic pathogens.
Consensus 7: patients should undergo anaesthesia
avoiding long-acting opioids. Patients should receive a
mid-thoracic epidural commenced preoperatively and
containing local anaesthetic in combination with a
low-dose opioid.
Consensus 8: patients should undergo laparotomy using
an abdominal incision of minimum length.
Figure 3.11 Enhanced recovery
after surgery (ERAS). After
Fearon et al (2005).

Preadmission
counselling
No bowel preparation
Fluid and
carbohydrate-loading/
on fasting

Early removal
of catheters
No premedication

Stimulation
of gut motility

ERAS

No nasogastric tubes

Prevention of nausea
and vomiting

Mid-thoracic epidural
anaesthesia/analgesia

Non-opiate oral
analgesics/NSAIDs

Short-acting
anaesthetic agent

Routine mobilisation
care pathway
Warm air body
heating in theatre

Short incisions,
no drains

Avoidance of sodium/
fluid overload

125

126

Chapter 3

Perioperative Care

Consensus 9: nasogastric decompression tubes should not

be used as a routine in the postoperative period.
Consensus 10: intraoperative maintenance of normothermia with infusion of warmed fluids and an upperbody forced-air heating cover should be used routinely.
Consensus 11: drains are not recommended following
routine colonic resection.
Consensus 12: it is recommended that urinary bladder
drainage is used for the duration of thoracic epidural
analgesia. Earlier removal of urinary drainage may be
considered before the epidural is stopped.
Consensus 13: antiemetics should be used selectively and
in a structured manner to diminish postoperative nausea
and vomiting and promote an early return of oral intake.
Consensus 14: patients should undergo a structured pattern of care to avoid postoperative ileus and promote
early oral intake.
Consensus 15: patients should receive continuous epidural
mid-thoracic low-dose local-anaesthetic/opioid combinations for 2 days after colonic resection. Paracetamol
should be given as a base-line analgesic (4 g daily)
throughout the postoperative course. For break-through
pain, NSAIDs and bolus epidural bupivacaine should be
given whilst the epidural is running. NSAIDs should be
started just before removal of the epidural and continued
until and/or after discharge.
Consensus 16: patients should be encouraged to commence
oral food intake 4 hours after surgery. Oral nutritional
supplements should be taken (approximately 400 mL
energy-dense oral nutritional supplements) from the day
of surgery until a normal level of food intake is achieved.
Continuation of oral nutritional supplements at home is
recommended for nutritionally depleted patients.

Consensus 17: patients should be nursed in an environment that encourages independence and mobilisation.
A care plan that facilitates patients being out of bed for
2 hours on the day of surgery and 6 hours thereafter is
recommended.
Consensus 18: planning the discharge process should
begin when the patient attends for preadmission
counselling. Defined discharge criteria should be
followed:
good pain control with oral analgesia
taking solid food, no intravenous fluids
independently mobile or same level as prior to admission
all of the above and willing to go home.
Consensus 19: surgical units undertaking an enhanced
recovery programme must be restructured to provide
adequate follow-up and continuity of care. An enhanced
recovery programme should only be initiated once there
is a clear pathway established for the prompt and safe
readmission of the 13% of patients who will experience
an anastomotic leak (or other major complications) at
home.
Consensus 20: audit is an inherent and essential component of every enhanced recovery programme.

Many of these recommendations are not contentious

but others do reflect a departure from what has until
now represented conventional care. The proponents of
enhanced recovery state (Lassen et al, 2005) that surgical
patients remain exposed to unnecessary starvation, suboptimal stress reduction and fluid overload. While further
outcome studies are required, enhanced recovery with or
without early hospital discharge is clearly desirable after
colon and rectal surgery.

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