Method for predicting postoperative bowel paresis in planned abdominal surgery

Abstract

FIELD: anesthesiology; resuscitation.SUBSTANCE: following is determined before surgery: risk of surgery, presence of coronary heart disease, presence of cancer, presence of advanced cancer, and duration of voluntary threshold apnea in seconds. The risk of developing postoperative intestinal paresis is determined using an original formula.EFFECT: preoperative prediction of the development of intestinal paresis after abdominal surgery.1 cl, 2 tbl, 2 ex

Description

[0001] The proposed invention relates to medicine, namely to anesthesiology and resuscitation, and can be used in assessing the risk of developing postoperative intestinal paresis during operations on abdominal organs.

[0002] Management of patients after extensive abdominal surgeries is an extremely pressing issue (Nors J., Funder JA, Swain DR Postoperative paralytic ileus after cytoreductive surgery combined with heated intraperitoneal chemotherapy. Pleura Peritoneum. 2019;5). After surgery on the abdominal organs, patients often experience impaired muscle tone as a result of functional or organic innervation lesions. Suppression of gastrointestinal motility is also observed, which leads to accumulation and delayed passage of gases and stool (Sanfilippo F., Spoletini G. Perspectives on the importance of postoperative ileus. Curr Med Res Opin. 2015;3:675-6). At the same time, patients note the absence of peristaltic sounds or their noticeable decrease when listening and an increase in the volume of the abdominal cavity.In the literature, paresis is also called functional intestinal obstruction, postoperative flatulence, dynamic intestinal obstruction, paralytic intestinal obstruction, or functional congestion (Turgunov Y., Shakeyev K., Sharapatov Y. et al. The model of acute obstructive pyelonephritis for studying bacterial translocation of E. coli from the gastroenteric tract. Open Access Maced J Med Sci. 2022;10:232-5).

[0003] Paresis is one of the most common postoperative complications (Khomyakov EA, Rybakov EG Postoperative paresis of the gastrointestinal tract. Khirurgiya. 2017;3:76-85). Despite significant advances in modern surgery and anesthesiology, the incidence of postoperative paresis in patients is 10-17% (Khomyakov EA, Ponomarenko AA, Rybakov EG Neostigmine in the treatment and prevention of postoperative gastrointestinal paresis. Meta-analysis and systematic literature review. Coloproctology. 2016;3:91-101). According to other data, the incidence of postoperative complications accompanied by paresis ranges from 5% to 50% (Luckey A. Mechanisms and treatment of postoperative ileus. Arch Surg. 2003;138:206-14). Intestinal paresis leads to impaired peristalsis, difficulty in food passage, and the development of intestinal obstruction. This increases the risk of abdominal infection and requires repeated surgeries (Venara A., Meillat H., Cotte E. et al.Incidence and risk factors for severity of postoperative ileus after colorectal surgery: a prospective registry data analysis. World J Surg. 2020; 44: 957-966).

[0004] Thus, the relevance of predicting intestinal paresis in abdominal surgery is that it allows for timely detection and prevention of its possible development, which reduces the risk of complications and improves the prognosis for the patient.

[0005] One of the analogues is the assessment of the initial physical status according to the classification of the American Society of Anesthesiologists (ASA). The method involves assigning the patient to one of the classes (from 1 to 6), depending on the severity of comorbidities (Hurwitz EE, Simon M, Vinta SR. et al. Adding examples to the ASA-physical status classification improves correct assignment to patients. Anesthesiology. 2017;126:(4):614–622 10.1097 / ALN.0000000000001541).

[0006] Disadvantages of the method:

[0007] 1. Subjectivity.

[0008] 2. The method does not take into account the impact of the trauma of the surgical intervention.

[0009] 3. Insufficient forecasting accuracy.

[0010] 4. It is an adapted tool for assessing the risk of developing BKO.

[0011] Another analogue of the proposed method is a method for predicting the risk of developing postoperative intestinal paresis, based on determining the temperature of the mucous membrane and skin of the cheeks (Madyarov V., Kuzikeev M., Malgazhdarov M. et al. A forecasting method of postoperative intestinal paralysis and its timely resolution. Prz Gastroenterol. 2023; 18 (4): 393-401). According to this technique, the initial values ​​​​of the temperature of the mucous membrane and skin of the cheeks were measured in patients, after which the difference between these values ​​​​(t1) was calculated. Then the patients took xanthinol nicotinate. After 15-20 minutes, the difference in temperatures between the mucous membrane and skin of the cheeks (t2) was measured again. Then the temperature coefficient (T) was calculated using the following formula: T = t1 - t2. At T ≥ 1, the development of postoperative atony was considered unlikely.

[0012] The main disadvantages are:

[0013] 1. Ambiguous results: the temperature of the mucous membrane and skin of the cheeks may be elevated or lowered due to various factors not related to the development of postoperative intestinal paresis.

[0014] 2. Insufficient accuracy: The method based on detecting the temperature of the mucous membrane and skin of the cheeks may not be accurate enough to accurately determine the risk of developing postoperative intestinal paresis.

[0015] 3. The need for combined diagnostic methods: to reliably predict the risk of developing postoperative intestinal paresis, it is necessary to use not only temperature measurement, but also other diagnostic methods.

[0016] The closest analogue of the method is the model for predicting poor recovery of gastrointestinal function in the postoperative period after gynecological surgeries (Wang B., Hu L., Hu X. et al. Exploring perioperative risk factors for poor recovery of postoperative gastrointestinal function following gynecological surgery: A retrospective cohort study. Heliyon. 2023;10(1):e23706). The model included the following variables: preoperative use of oral laxatives, history of abdominal surgery, and cancer surgery, assigning 1 point to each of these variables. A score of 0 points predicted a 3.2% risk of developing postoperative gastrointestinal dysfunction; 1 point – the risk was 5.5%; with a value of 2 points or more – 19.4%. The AUROC of this model was 0.759.

[0017] The disadvantages of this method are:

[0018] 1. Insufficient information about patient parameters: The prediction model may not take into account the individual characteristics of each patient, such as their age, health status, presence of comorbidities, etc.

[0019] 2. Lack of data on the risk of complications: The model may not take into account all possible complications of the postoperative period, which may lead to underestimation of the risk of poor recovery of gastrointestinal function.

[0020] 3. Need for further research: To make a more accurate prognosis, further research is needed to clarify the parameters that influence the restoration of gastrointestinal function after gynecological surgery.

[0021] 4. Insufficient forecasting accuracy.

[0022] TASK: to increase the accuracy of predicting postoperative intestinal paresis in planned abdominal surgery.

[0023] Technical result – the proposed method makes it possible to identify patients with a high risk of developing postoperative intestinal paresis after abdominal operations by determining preoperative risk factors that reliably influence the occurrence of these adverse outcomes, which is necessary for optimizing the perioperative period in these patients.

[0024] The essence of the proposed method is to determine the risk of surgery (F1, F2) before surgery, identify the presence of coronary heart disease (CHD) (F3), oncological disease (F4), widespread oncological disease (F5), determine the duration of arbitrary threshold apnea in seconds (F6), and then determine the risk of developing postoperative intestinal paresis according to the formula: K = (-6.289) + F1 x 1.528 + F2 x 2.035 + F3 x 0.388 + F4 x 1.530 + F5 x 0.790 + F6 x (-0.013), wherein the risk of surgery is determined depending on the location and type of surgical intervention, and F1 is taken as 1 if the surgery is of medium risk and as 0 if it is of low or high risk; F2 is taken as 1 if the surgery is of high risk and as 0 if it is of low or medium risk; F3 is taken as 1 in the presence of coronary heart disease, and 0 in its absence; F4 is taken as 1 in the presence of oncological disease, and 0 in its absence;F5 is taken equal to 1 in the presence of a widespread oncological disease, and 0 in the case of a localized oncological disease; F6 is taken equal to the duration of an arbitrary threshold apnea in seconds; and if the K value is greater than -3.94, the patient is classified as a high-risk group for developing postoperative intestinal paresis, and if the K value is equal to -3.94 or less, the patient is classified as a low-risk group.

[0025] The proposed method was justified as follows. A study of 11,488 patients undergoing abdominal surgery with an initial physical status of ASA classes 1-3 was conducted. Preoperative factors were recorded, including the presence of coronary artery disease, cancer, and advanced cancer (i.e., the presence of metastases). The risk of surgical intervention was determined, and a breath-hold test was performed during which the duration of voluntary threshold apnea was assessed in seconds. The development of postoperative intestinal paresis was recorded within 30 days after surgery.

[0026] The risk of surgical intervention was determined according to the data in Table 1.

[0027] Table 1

[0028] Assessment of the risk of surgical intervention depending on the location and type of surgery (Halvorsen S., 2022)

[0029] Low risk Medium risk High risk • Breast surgery • Dental surgery • Thyroid surgery • Ophthalmological surgery • Minor gynecological surgery • Minor orthopedic surgery (meniscectomy) • Reconstructive surgery • Superficial surgery • Minor urological surgery (transurethral resection of the prostate) • Video-assisted minor lung resection • Carotid revascularization • Endovascular aortic aneurysm repair • Head and neck surgery • Abdominal surgery: splenectomy, hiatal hernia repair, cholecystectomy • Minor thoracic surgery • Major neurological or orthopedic surgery (hip, spine) • Peripheral arterial angioplasty • Kidney transplant • Major urological or gynecological surgery • Adrenal resection • Aortic and major vessel surgery • Duodenal-pancreatic surgery • Liver resection, bile duct surgery • Esophagectomy • Open lower limb revascularization or amputation • Pneumonectomy • Lung or liver transplantation • Correction of intestinal perforation • Total cystectomy

[0030] The prevalence of cancer was characterized by the presence of malignant cells in the lymph nodes or other organs (Sheremet D.V., 2015).

[0031] The conducted logistic regression analysis showed that the risk of surgical intervention, the presence of coronary heart disease, cancer, widespread cancer and the duration of voluntary threshold apnea significantly affect the risk of developing postoperative intestinal paresis (Table 2).

[0032] Table 2

[0033] Multivariate analysis of factors independently associated with intestinal paresis

[0034] Variable Coefficient OSH p Constant -6,289 0,54 <0,001 Average risk of surgery (F 1) 1,528 0,47 0,001 High risk of surgery (F 2) 2,035 0,49 <0,001 Ischemic heart disease (F 3) 0,388 0,19 0,04 Oncological disease (F 4) 1,530 0,24 <0,001 Common cancer (F 5) 0,790 0,24 0,001 Duration of voluntary threshold apnea, sec (F 6 ) -0,013 0,008 0,04

[0035] The prognosis of postoperative intestinal paresis is determined by the formula:

[0036] K=(-6.289)+F1x1.528+F2x2.035+F3x0.388+F4x1.530+F5x0.790+F6x(-0.013)

[0037] The numerical coefficients were identified and substantiated by conducting logistic regression analysis and ROC analysis. F1 is the risk of surgery (taken as 1 if the risk is average, and 0 otherwise), F2 is the risk of surgery (taken as 1 if the risk is high, and 0 otherwise), F3 is the presence of coronary heart disease (taken as 1 if present, and 0 if absent), F4 is the presence of cancer (taken as 1 if present, and 0 if absent), F5 is the presence of widespread cancer (taken as 1 if present, and 0 if absent), F6 is the duration of voluntary threshold apnea after the breath-holding test on inspiration in seconds.

[0038] If the K value is more than -3.94, the patient is classified as a high-risk group for developing postoperative intestinal paresis; if the K value is -3.94 or less, the patient is classified as a low-risk group.

[0039] The conducted ROC analysis confirmed the good prognostic value of the developed method (the area under the ROC curve was 0.82). The sensitivity and specificity for the obtained cutoff point were 82% and 76%, respectively.

[0040] The proposed method can be used in practical healthcare, does not require special conditions for implementation, is time-saving, and easy to operate.

[0041] Examples of application of the method

[0042] 1. Patient K., 62 years old, was referred for surgery due to gastric oncopathology.

[0043] Concomitant diseases:

[0044] • Oncological disease: confirmed

[0045] • Common oncological disease: absent

[0046] • IHD: no

[0047] • Surgical risk: moderate (laparoscopic surgery is planned)

[0048] • Stange test: 64 seconds

[0049] The obtained values ​​are substituted into the developed equation:

[0050] K=(-6,289)+1x1,528+0x2,035+0x0,388+1x1,530+0x0,790+

[0051] 64x(-0.013)=-6.289+1.528+0+1.530-0.832=-4.06

[0052] Because K is less than -3.94, the patient is classified as low-risk. The patient did not develop intestinal paresis postoperatively.

[0053] Patient K., 71 years old, was admitted for planned surgical intervention on the stomach (gastrectomy).

[0054] Risk factors:

[0055] • Oncological disease - yes

[0056] • Common oncological disease - absent

[0057] • IHD - confirmed in the anamnesis

[0058] • Operational risk is high

[0059] • Duration of PPA - 35 seconds

[0060] The obtained values ​​are substituted into the developed equation:

[0061] K=(-6,289)+0x1,528+1x2,035+1x0,388+1x1,530+0x0,790+

[0062] 35x(-0.013)=-6.289+0+2.032++1.530+0.388-0.455=-2.79

[0063] Because K is greater than -3.94, the patient is classified as high-risk. Postoperatively, intestinal paresis developed on the second day after surgery.

[0064] Thus, the use of the proposed method allows us to predict the development of postoperative intestinal paresis.