Nausea, vomiting and return of bowel function after colorectal surgery Karen L. Barclay,*† Ying-Yan Zhu† and Mark A. Tacey‡§ *Department of General Surgery, Northern Health, Melbourne, Victoria, Australia †Northern Clinical School, Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia ‡Northern Clinical Research Centre, Northern Health, Melbourne, Victoria, Australia §Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
Key words colorectal surgery, enhanced recovery after surgery, gastrointestinal function, general surgery, ileus, morphine, nausea and vomiting. Correspondence Dr Karen L. Barclay, The Northern Hospital, 185 Cooper Street, Epping, Vic. 3076, Australia. Email: [email protected]
K. L. Barclay FRACS, MBChB; Y.-Y. Zhu MBBS; M. A. Tacey BSc, GradDip (Biostats). This study was accepted as a poster to the Australasian College of Surgeons Annual Scientific Congress, Auckland, New Zealand 2012. Accepted for publication 11 July 2015. doi: 10.1111/ans.13290
Abstract Background: Although patterns of return of bowel function (ROBF) following colorectal surgery with enhanced recovery after surgery (ERAS) programmes have been well delineated, regular morphine use is uncommon. This study describes the patterns of post-operative nausea and vomiting (PONV) and ROBF in this context. Method: Patients undergoing elective major colorectal surgery on an ERAS programme over 1 year were included. Patient details, intra-operative course, postoperative management, outcomes and complications were collected retrospectively from clinical records. Statistical analysis was performed using Stata version 12. Results: A total of 136/142 (96%) patients received morphine for post-operative analgesia. Most (112/142, 79%) experienced either no vomiting (87/142, 61%) or small amounts (25/142, 18%). On average, patients without an ileostomy passed flatus and opened their bowels after 2.4 and 4.3 days, those with an ileostomy taking 1.5 and 2.1 days. Vomiting was not related to ROBF (P = 0.370) or overall complications; wound complications (odds ratio (OR) = 8.1, 95% confidence interval (CI): 2.0–32.5), electrolyte abnormalities (OR = 2.9, 95% CI: 1.2–7.1) and length of stay (hazard ratio = 1.3, 95% CI: 1.2–1.5) were related. Conclusion: Most patients do not experience PONV in this context. ROBF is predictable without prolonged delays. This information could be used to allow confident early discharge and identify patients whose deviation from normal may indicate complications.
Introduction Post-operative nausea and vomiting (PONV) and delayed return of bowel function (ROBF) hinder recovery after colorectal surgery.1 PONV may be more distressing than post-operative pain2,3 and is associated with prolonged length of stay, wound dehiscence, electrolyte imbalances, bleeding, oesophageal rupture and pulmonary complications.4,5 Likewise, delayed ROBF can lead to greater catabolism, decreased mobilization, poorer wound healing, increased risk of infection and suboptimal nutrition.6 A range of evidence-based peri-operative interventions have been integrated into ‘fast track’ or ‘enhanced recovery after surgery (ERAS)’7 programmes. These aim to attenuate the surgical stress response and enhance recovery. Anti-emetic prophylaxis, avoiding long-acting opiates, minimizing excessive fluid administration and thoracic epidurals, exert positive influences on PONV and ROBF. © 2015 Royal Australasian College of Surgeons
Although morphine is supposed to be avoided due to its detrimental effects on these outcomes, the extent of use may not be clear when patterns and implications of PONV and ROBF are described. The aim of this study was (i) to describe the patterns of PONV and ROBF in an ERAS programme with routine morphine use and (ii) to assess the relationship between post-operative gastrointestinal function and outcomes.
Methods General Patients undergoing elective major colorectal surgery 1 June 2010 to 30 May 2011 at the Northern Hospital were identified. All were on the ERAS protocol (Table S1). There were no exclusions. Analysis was on an intention-to-treat basis. ANZ J Surg 85 (2015) 823–828
Barclay et al.
Table 1 Patient demographics and operative details (n = 142)
This study was approved by the Northern Health Ethics: A23/10.
Age (years, mean ± SD) Gender Male Female BMI, mean ± SD Smoking Never smoked Ex-smoker Current ECOG status 0 1 2 3 ASA score I II III Operation method Open Laparoscopic Procedures Right-sided resection Left-sided resection APR/Hartmann’s Low/ultralow rectal Multisegmental Pelvic exenteration Stoma Ileostomy Colostomy
Patient details, intra-operative course, post-operative management and complications were collected retrospectively from clinical records by a single individual. Analgesia and nasogastric use, PONV and passage of flatus and bowel motions were taken from the daily checklist (Y/N documented each 8 h), progress notes and fluid balance. Where vomiting was measured, this volume was used. If ‘small amounts’ the volume was documented as