Colon Resection Periprocedural Care

The following are links to patient education resources:

• Drexel University College of Medicine, Division of Colorectal Surgery
• Susan Cohan Colon Cancer Foundation
• Crohn's and Colitis Foundation of America
• STOP Colon/Rectal Cancer Foundation
• American Society of Colon and Rectal Surgeons
• United Ostomy Association
• Wound Ostomy Continence (WOC) Nursing

Elements of informed consent

The authors discuss the risks, benefits, and alternatives of the planned procedure with every patient. The perioperative outcomes are also discussed, as well as the disease-specific outcomes.

Nutritional status is important, in that the morbidity increases in patients who are malnourished. If a preoperative albumin level is lower than 3 g/dL, supplemental nutrition is prescribed, and if feasible, the surgery is delayed. Anemia is also important to note preoperatively. The authors routinely prescribe supplemental ferrous sulfate for anemic patients.

Patients with a history of pelvic phlegmon, those undergoing repeat rectal surgery (eg, for recurrent cancer or Crohn disease), and those with a history of distant radiation therapy receive ureteral stents. Whether routine ureteral stenting is warranted is a matter of debate. ^[27] The authors do not believe in routine stenting and encourage surgeons to use their judgment to determine whether stents are needed for specific individual cases.

Standard surgical instruments are required for colon resections. In addition to the standard abdominal tray, abdominal retractors and stapling devices are also often used. The classic abdominal-wall retractors include a Buchwalter and a Balfour. These stretch the abdominal wall to allow exposure of the abdominal cavity.

Intestinal staplers are also commonly used. There are linear cutting staplers, circular staplers, and staplers that simply staple an end of intestine. Laparoscopic staplers are also available.

Energy devices can be used to facilitate coagulation of blood vessels and dissection. Regardless of the energy source, the goals of using energy devices are to quickly coagulate tissue, to minimize the risk of arcing current and injuring other structures, and to have a small diameter of thermal spread. Common instruments include the LigaSure from Covidien and the Harmonic and Enseal from Ethicon Endosurgery.

If laparoscopic colectomy is to be performed, atraumatic bowel graspers, a 30° laparoscope, and a wound protractor for specimen extraction are needed. Robotic colectomy has also become more commonplace, and robotic techniques have become part of the minimally invasive approach to colectomy.

Classic bowel preparation is becoming controversial. Traditionally, on the day before surgery, patients should drink only clear liquids. Patients should be on nil per os (NPO) status past midnight, except for medications. Polyethylene glycol may be given as a bowel preparation. The authors also prescribe neomycin and erythromycin (Nichols preparation) in order to decrease the intraluminal bacterial counts preoperatively in combination with the mechanical bowel preparation (MBP).

The authors’ current practice is as follows: No dietary changes are required the day before surgery for a right colectomy, and no bowel preparation is needed. For left colectomy, sigmoid colectomy, or low anterior resection (LAR), MBP is prescribed in conjunction with a Nichols preparation. In the operating room after induction, rectal irrigation is performed with dilute povidone-iodine in saline via a mushroom catheter and cystoscopy tubing. The lower colon and rectum must be thoroughly cleansed and emptied just before the start of surgery because the rectum is accessed to perform the anastomosis.

In January 2019, the American Society of Colon and Rectal Surgeons (ASCRS) issued the following recommendations for bowel preparation in elective colon and rectal surgery ^[28] :

• MBP combined with preoperative oral antibiotics is typically recommended for elective colorectal resections
• Preoperative MBP alone, without oral antibiotics, is generally not recommended for patients undergoing elective colorectal surgery
• Preoperative oral antibiotics alone, without MBP, are generally not recommended for patients undergoing elective colorectal surgery
• Preoperative enemas alone, without MBP and oral antibiotics, are generally not recommended for patients undergoing elective colorectal surgery

Enhanced recovery after surgery (ERAS) protocols have become mainstream and have been shown to decrease length of stay. ERAS protocols vary from one institution to another, but in general, their hallmarks include the following ^[29] :

• Multimodal pain management to decrease the use of narcotics, including transversus abdominis anesthetic blocks
• Goal-directed fluid therapy intraoperatively using monitors such as the Flotrac (Edwards Lifesciences)
• Preoperative carbohydrate loading
• Postoperative early ambulation

Many medications used to treat pain after surgery (eg, acetaminophen, oxycodone, and hydromorphone) are narcotics or opiates. When opiates bind to opiate receptors (eg, mu and delta) on gut smooth muscle, gastrointestinal (GI) motility is decreased. Alvimopan, acting as a mu opioid receptor antagonist, blocks the GI effect of opiates.

Alvimopan is a US Food and Drug Administration (FDA)-approved medication that decreases the length of postoperative ileus after bowel resection, thereby helping the bowel recover more quickly after bowel surgery and allowing the patient to resume eating solid foods and having regular bowel movements. It is usually taken once before surgery and twice a day after surgery for up to 7 days or until hospital discharge.

Efficacy trials have shown that in comparison with placebo, alvimopan reduces postoperative morbidity and lowers the incidence of prolonged hospital stay or readmission. One study showed that alvimopan decreased the length of hospital stay by 18 hours, as measured by time to discharge orders being written. ^[30]

The authors have added gabapentin and intravenous (IV) acetaminophen to their pain regimen to decrease narcotic dependence.

Preoperative IV antibiotics are given as per the Surgical Care Improvement Project (SCIP) guidelines. The authors also administer heparin subcutaneously (5000 U) 1 hour prior to surgery to aid in the prevention of deep vein thrombosis (DVT).

Anesthesia

Colectomies are usually performed with general anesthesia. Patients undergoing general anesthesia require intubation because the diaphragm is paralyzed. General anesthesia is the preferred method for performing colectomies because it paralyzes the abdominal-wall musculature, facilitating exposure and retraction of tissue.

An alternative method of anesthesia for performing colectomies is combined spinal-epidural anesthesia. This method may be appropriate for patients with conditions that cause breathing difficulties, such as severe kyphosis, chronic obstructive pulmonary disease (COPD), or restrictive lung diseases. In such patients, the concern of general anesthesia is the possibility of further respiratory failure that might result in prolonged intensive care management and mechanical ventilation. ^{[31, 32]}

Combined spinal-epidural anesthesia allows the patient to remain awake and unintubated throughout the entire procedure while eliminating sensation from the field of surgical operation. The fact that the diaphragm is not paralyzed in spinal-epidural anesthesia can be a disadvantage in laparoscopic cases. The pressure exerted on the diaphragm by insufflation can cause great discomfort to the patient. If this discomfort were to become intolerable, the procedure would have to be converted to an open procedure.

Positioning

The patient's arms should be tucked in when possible. For left colectomy, sigmoid colectomy, and LAR, the patient is placed in the lithotomy position. Depending on the surgeon's preference and the patient's body habitus, the Lloyd-Davies position may be used.

The Lloyd-Davies position is a modified lithotomy position with 30° of Trendelenburg and the hips flexed at 15°. The advantage of this position is that it provides good exposure for operations in the pelvic area. The disadvantage is that the Trendelenburg position could cause limb ischemia, especially in procedures lasting longer than 5 hours, followed by an increased risk of lower-limb compartment syndrome during the reperfusion period. ^[33]

For right colectomy and abdominoperineal resection (APR), the authors place the patient in the supine position. For APR, after completing the mobilization of the rectum and creating the colostomy, the authors close the abdomen and place the patient in the prone jackknife position and complete the operation. The exposure from the prone position warrants the time taken to reposition the patient.

For pelvic surgery, it is imperative that patient is secured so that he or she does not slide off the bed toward anesthesia while in the Trendelenburg position. The authors use a beanbag and padded foam on the mattress to add friction. The authors also tape the patient's chest for laparoscopic cases; tilting the patient may be required to facilitate exposure.

Wound and stoma care

Wounds and stomas must be examined daily. Both the intactness of the stoma and the output from it must be monitored. If stoma output exceeds 2 L/day, it may be necessary to start loperamide. Like patients with high-output enterocutaneous fistulas, patients with high-output stomas are at risk for electrolyte imbalance and dehydration. Therefore, losses may have to be replaced with IV fluids.

Drains

Abdominal drains and subcutaneous drains are placed to bulb suction. Patients who develop deep pelvic abscesses postoperatively may require drain tube placement by interventional radiology. Drains may be removed in a few days when the output has markedly decreased.

Antibiotics

Antibiotics can be discontinued within 24 hours of surgery unless gross spillage or purulence was encountered during the procedure.

Venous thromboembolism prophylaxis

Unless contraindicated, patients should be continued postoperatively on heparin 5000 units subcutaneously three times a day or low-molecular-weight heparin (LMWH) daily. Patients should also wear sequential compression devices while in bed.

Diet

The authors believe that nasogastric and orogastric tubes need not be kept in place postoperatively and thus should be removed immediately at the end of the case. However, a nasogastric tube may have to be inserted if postoperative ileus develops. A nasogastric tube does not shorten the duration of postoperative ileus but does relieve the symptoms of nausea, vomiting, and bloating.

On the day of surgery, the patient may be started on sips of clear liquids. The diet is advanced as tolerated. The surgeon should use his or her clinical judgment to determine when to discontinue IV fluids.

Activity

The patient should sit up in a chair for all meals.

The head of the patient’s bed should be elevated 30° or higher.

Although data have suggested that relief of bloating and cramps after ambulation may be more perceived than real, ^[34]  it is the authors' perspective that ambulation at least does no harm and is a form of venous thromboembolism (VTE) prophylaxis and that patients should be aggressively ambulated.

Respiratory

As with all surgical procedures, incentive spirometry is key to preventing atelectasis and its attendant pneumonia. Incentive spirometry should be practiced at least 10 times every hour. Oxygen therapy can be weaned to room air starting the morning after surgery.

Foley catheters

In most cases, indwelling urinary catheters can be removed the day after the procedure. However, for patients who have undergone LAR, APR, or ileal pouch–anal anastomosis (IPAA), the urinary catheter ought not to be discontinued until at least postoperative day 2. The reason why these patients need additional time for indwelling catheterization is that these operations are more likely to disrupt the autonomic nerves that innervate the pelvic viscera. ^[35]

If a patient is unable to void 6 hours after urinary catheter removal, bladder ultrasonography must be performed immediately. An estimated urine volume of 200 mL or greater would be grounds for recatheterization, via either a Foley or a straight catheter. In some instances, urinary retention may present as overflow incontinence. Patients with diabetes or benign prostatic hyperplasia are especially prone to overflow incontinence, the former because of autonomic neuropathy and the latter owing to mechanical obstruction of outflow from the bladder.

Overflow incontinence typically presents as a constant dribbling of urine or frequent urination of small amounts. In such cases, the patient may still be discharged from the hospital but with a Foley catheter left in place and a urine bag attached to the leg. Thorough evaluation of the patient's ability to empty the bladder, along with assistance from a urologist, is essential to the patient's postoperative progress.

Laboratory studies

Daily laboratory studies are usually not necessary unless justified by the patient’s clinical condition (eg, high-output stoma).

Blood transfusion

The authors consider a blood transfusion for patients with a hemoglobin level lower than 7 g/dL or those with symptoms of anemia (eg, fatigue, pale skin, tachycardia, dizziness, cold extremities).

Ostomy management

Patients with colostomy need enterostomal nursing care and education on how to take care of the stoma at home. Many patients benefit from a home visit by a nurse. The operation performed and the type of ostomy created dictate when and how the patient can have sex—for example, whether a gay man can engage in receptive anal intercourse (RAI). Such issues are sensitive ones that patients might be reluctant to raise but that nevertheless should be addressed by either the surgeon or the enterostomal therapy nurse.

Diversion colitis

Diversion colitis is an inflammatory process that occurs in segments of bowel that have been "diverted" from the fecal stream (ie, after ileostomy or colostomy). It is thought to result from lack of exposure of colonocytes in the diverted segment to short-chain fatty acids. Most cases of diversion colitis are asymptomatic and do not require long-term monitoring. Diversion colitis is not associated with an increased risk for cancer. In symptomatic cases, the restoration of intestinal continuity is generally curative.

Colorectal cancer

If the cancer is a stage III, the authors refer the patient to a medical oncologist for adjuvant therapy. Patients with stage II cancers with specific features are also referred for postoperative chemotherapy.

The American Society of Colon and Rectal Surgeons (ASCRS) has issued practice guidelines for surveillance of patients who have undergone curative treatment of colon and rectal cancer. ^[36]

Long-term follow-up

Patients should be seen at 2 weeks and 6 weeks postoperatively and should receive instructions on what to look for and what to eat.