for Patients and OR Team in Preparation for Laparoscopic Colorectal Surgery

ASA PS classification

Definition

Examples, including, but not limited to:

ASA I

A normal healthy patient

Healthy, non-smoking, no or minimal alcohol use

ASA II

A patient with mild systemic disease

Mild diseases only without substantive functional limitations. Examples include (but not limited to) current smoker, social alcohol drinker, pregnancy, obesity (30< BMI <40), well-controlled DM/HTN, mild lung disease

ASA III

A patient with severe systemic disease

Substantive functional limitations: one or more moderate to severe diseases. Examples include (but not limited to) poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA <60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents.

ASA IV

A patient with severe systemic disease that is a constant threat to life

Examples include (but not limited to) recent (<3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD, or ESRD not undergoing regularly scheduled dialysis

ASA V

A moribund patient who is not expected to survive without the operation

Examples include (but not limited to) ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction

ASA VI

A declared brain-dead patient whose organs are being removed for donor purposes

DM diabetes melitus, HTN hypertension, ESRD end-stage renal disease, MI myocardial infarction, TIA transient ischemic attack, CVA cerebrovascular accident, DIC disseminated intravascular coagulation, CAD coronary artery disease

Used with permission of the American Society of Anesthesiologists [1]

Extremes of body mass index (BMI) (<20 kg/m² or >35 kg/m²) are associated with significant risk of 30-day mortality, and BMI >35 kg/m² is associated with increase in 30-day morbidity (urinary tract infection, wound infection, sepsis, VTE) [2, 3]. These patients should undergo nutrition counseling at first preoperative visit in order to optimize weight and nutritional status before surgery. A conversation between the operating surgeon and the morbidly obese patient should occur communicating the increased risk of morbidity and mortality incurred based on the patient’s BMI. An anesthesia preoperative assessment is also recommended for these patients, as factors such as challenging airways can exist.

The goal of preoperative cardiac risk assessment is to identify those who have recently experienced myocardial infarction (MI) and those at high risk of perioperative MI in order to prevent perioperative cardiac complications. Recent MI requiring percutaneous coronary intervention presents a challenge due to the requirement of dual antiplatelet therapy (aspirin and clopidogrel) in the post intervention period [4, 5]. Bare-metal stents require antiplatelet therapy for a minimum of 4–6 weeks post procedure and drug-eluting stents a minimum 1 year post procedure before stopping for elective surgery [4, 5]. In the setting of malignancy or acute ulcerative colitis, one may not have the ability to concede to these time restraints . Therefore, the risk of perioperative MI versus postoperative bleeding on antiplatelet therapy must be carefully weighed, and a discussion between cardiologist, surgeon, and patient is of utmost importance in such circumstances. Some institutions have their own policies on this and continue at least aspirin throughout the operation on patients with cardiac stents.

The Revised Cardiac Risk Index (RCRI) [6] and Gupta score [7] are two clinical indices commonly used to assess patients at high risk for experiencing perioperative cardiac events. Patients with scores predicting higher risk may need more extensive diagnostic investigation and possible intervention prior to elective surgery. For example, in the RCRI (Box 9.2) for each risk factor, a patient is given a score of 1, and for those with a total score of ≥2, further testing may be of clinical utility. Patients with low scores do not need further testing. The Gupta score (Box 9.3) is scoring index that is also used to identify high-risk patients for perioperative cardiac complications [7]. This scoring index is reported to be more accurate than RCRI ; however, it is more difficult to calculate and, therefore, less frequently used. Patients with cardiac risk factors may be on a variety of anticoagulants. Standard recommendations for holding anticoagulants are included in Table 9.2.

Table 9.2

Recommend time for discontinuation of anticoagulation prior to surgery

Drugs	Mechanism of action	Hold time
Heparin	Promote antithrombin	6–12 hours
Low molecular weight heparin	Factor Xa inhibitor	12–24 hours
Warfarin	Vitamin K antagonist	5 days
Argatroban	Direct thrombin inhibitors	3–9 hours
Bivalirudin	Direct thrombin inhibitors	1.5–3 hours
Dabigatran	Direct thrombin inhibitors	24–96 hours (more if patient has renal impairment)
Rivaroxaban	Factor Xa inhibitor	24–48 hours
Apixaban	Factor Xa inhibitor	24–48 hours
Edoxaban	Factor Xa inhibitor	48 hours
Aspirin	Cyclooxygenase inhibitor	Unnecessary (7–10 days for reversal of effect)
Clopidogrel	Platelet P2Y12 receptor inhibitor	5 days
Prasugrel	Platelet P2Y12 receptor inhibitor	5 days
Ticagrelor	Platelet P2Y12 receptor inhibitor	5 days
Ticlopidine	Platelet P2Y12 receptor inhibitor	5 days

Box 9.1 Patient Factors Associated with Perioperative Complications

Patient factors

Age
Smoking
Dyspnea at rest or on exertion
Poor functional status
Cerebrovascular accident
Disseminated cancer
Preoperative open wound
Immunosuppression
Preoperative weight loss >10%
Preoperative anemia or need for >4 units of PRBC within 72 hours of surgery
Body mass index (BMI)
Preoperative leukocytosis

Box 9.2 Revised Cardiac Risk Index (RCRI)

Revised Cardiac Risk Index (RCRI): independent risk factors associated with increased incidence of perioperative cardiac events in patients undergoing non-cardiac surgery
1. 1.
  
  High-risk surgery
2. 2.
  
  Ischemic heart disease
3. 3.
  
  History of congestive heart failure
4. 4.
  
  History of cerebrovascular disease
5. 5.
  
  Insulin therapy for diabetes
6. 6.
  
  Preoperative serum creatinine >2.0 mg/dL

Box 9.3 Gupta Score

Gupta score: independent risk factors associated with greater potential to identify increased risk of perioperative cardiac event compared with RCRI
- ASA class
- Dependent functional status
- Age
- Abnormal creatinine (>1.5 mg/dL)
- Type of surgery

Special Considerations

Immune Suppression

Patients undergoing colon and rectal surgery may suffer from baseline immunosuppression for a variety of reasons. Patients with inflammatory bowel disease (IBD) are often taking a variety of medications including biologic agents, steroids, and thiopurines which impair their immune response, cancer patients may have been exposed to chemotherapy, transplant patients may require long-term immune suppression, and the malnourished may have baseline immune dysfunction. When possible, it is advantageous to stop immune suppression and allow it to wash out of the system; however, this is not often an option as stopping these medications could cause the patients to deteriorate and opens up other potential risks.

There is a significant body of literature demonstrating that steroids significantly increase the risk of septic complications during colon and rectal surgery [8–12]. This effect appears to be dose related, and it does seem clear that patients taking less than 20 mg of prednisone daily are at a lower risk of complications than those on more than 20 mg daily. These patients are still, however, at an increased risk of complications compared to those who are entirely off of steroids [12]. The use of perioperative stress-dose steroids has also fallen out of favor. Perioperative adrenal insufficiency is an extremely rare condition, and there is a greater risk of steroid-related complications [13]. Patients have been assessed for mild symptoms such as orthostasis in the perioperative period, and there is no difference based on whether they received a stress dose of steroids at the time of surgery [14]. The current recommendation is for the patient to take their standard steroid dose on the day of surgery and then begin a taper in the postoperative period. Stress-dose steroids should only be administered in the setting of symptomatic adrenal insufficiency. There is also excellent evidence showing that thiopurines do not appear to increase the risk of postoperative complications in patients with IBD [15].

There is much greater controversy surrounding the effect that biologics have on perioperative outcomes in IBD surgery. There have been several papers showing an increase in perioperative infection rate [16–18] and several and many others showing no increased rate of infection [19–22]. There are valid arguments on both sides as to whether biologic agents should be stopped or washed out of the system prior to surgery, but the full argument is well beyond the scope of this chapter. Likely biologic agents are markers for severity of disease, and patients who have failed multiple biologics likely have the most severe disease. This needs to be taken into consideration when planning surgery, and these patients should be treated as though they have more severe illness than they may exhibit. A common approach to patients on biologics is to wait until they are at the nadir of their dose, usually around the time they are about to receive their next dose, delay that dose, perform their surgery, and restart medication if medically necessary several weeks after surgery. It should be remembered that these patients still have active therapy in their system, and the only true way to ensure there is no drug present is to allow for a full washout which is equivalent to five half-lives of the medication (Table 9.3).

Table 9.3

Half-life and washout time of biologic treatments for IBD

Medication	Half-life (d)	Washout (d)
Infliximab	8–9.5	40–47.5
Adalimumab	14	70
Certolizumab	14	70
Golimumab	9–15	45–75
Vedolizumab	25	125
Natalizumab	10–11	40–45
Ustekinumab	15(IV) 45.6 (SQ)	75 (IV) 228 (SQ)
Tofacitinib	0.13	3

Half-lives and washout times for biologic therapies for IBD listed in days (IV intravenous, SQ subcutaneous)

Ideally, chemotherapy should be allowed to wash out of the patient’s system prior to undergoing elective colorectal procedures. Chemotherapy can impair wound healing, cause myelosuppression, impair immune responses, and lead to a variety of other different issues which can increase the risk of postoperative complications. When feasible, it is best to wait at least 6 weeks after any dose of chemotherapy to allow for washout. This is particularly true of bevacizumab, a monoclonal antibody against vascular endothelial growth factor (VEGF) , which impairs angiogenesis. These patients are at a significant risk of postoperative bleeding. Waiting for surgery is not always feasible, and in the acute setting, patients undergoing chemotherapy sometimes require urgent surgical intervention. When this occurs, it is always important to take the chemotherapy into consideration when planning the type of surgery and consider smaller, more temporizing procedures knowing that significant intervention may lead to significant complication.

Smokers

Smoking is a well-documented risk factor for complications after colon and rectal surgery. Smoking has shown to contribute to increased risk of VTE, wound infection, anastomotic dehiscence, and hernia formation [23–25]. The effects of smoking on the airway are also extensive. Carbon monoxide has deleterious effects on the cardiovascular system and can persist for several hours after inhalation. Airway sensitivity is increased, and these effects last 2–10 days after inhalation. Mucus secretion is also altered, and these effects can last for many weeks [26]. Smoking cessation should be instituted at least 4 weeks prior to surgery, and it has been shown that there is increasing benefit for every week beyond 4 that the patient is able to stop smoking [23]. However, for those who have quit smoking for less than 4 weeks, the alteration of mucus secretion may lead to greater risk of respiratory complications from general anesthesia, and ideally it is best to wait until mucus secretion and cilliation returns to its normal state [26].

One should consider canceling elective surgery in patients who are actively smoking, and any patient who actively smokes and presents for surgery should be counseled on smoking cessation techniques. The surgeon should seek help from the patient’s primary care physicia n as they will often have a greater depth of experience in assisting the patients to adequate cessation. Several aides have also been used in promoting smoking cessation. These include varenicline, bupropion, and nicotine replacement. In a randomized controlled trial, varenicline demonstrated a 3.6-fold increase in smoking cessation compared to placebo, while bupropion and nicotine replacement demonstrated a two-fold increase [27].

These techniques for smoking cessation are often not effective, and so many surgeons will test their patient’s blood, urine, or saliva for nicotine or the by-product of nicotine metabolism cotinine. Nicotine will only stay positive on a blood test for several days after consumption, whereas cotinine may remain positive for several weeks and is therefore a better test of long-term cessation than nicotine testing alone. It should be noted that patients taking nicotine replacement will also test positive for nicotine and cotinine, and so this should be taken into consideration when counseling patients on their optimal cessation technique.

Malnutrition

It is also critical to ensure your patient’s nutritional status is optimized prior to undergoing major abdominal surgery. Nutrition can be measured in many different ways, whether its body mass index (BMI), weight loss, or hypoalbuminemia. It is important to take all of these into consideration when evaluating a patient for surgery, but the single best test is likely hypoalbuminemia, which has been shown to be the best predictor of most surgical complications as well as length of stay and overall complication rates when compared to weight loss and BMI in patients with colorectal cancer [28]. Malnutrition has been shown to increase the risk of almost every potential complication, from a variety of infectious and septic conditions, to VTE and DVT, to anesthesia-related complications, as poor nutrition impairs every major organ system, leaving patients open to postoperative dysfunction.

Improving upon patient nutrition prior to surgical intervention is necessary to minimize the risk of complications. Patients who are at risk for malnutrition should be assessed prior to surgery with an albumin and prealbumin levels. It should be remembered that albumin is a better marker of chronic nutrition with a half-life of 20–22 days, while prealbumin has a half-life of 2–4 days and is a better gauge of the direction a patient’s nutrition is trending. If a patient is determined to be malnourished, then intervention should be considered. Intervention should be chosen based on the factors which led to the patient’s malnutrition as well as the acuity of the problem and the timing of surgical intervention. Generally those who are in a catabolic condition should take in between 1.5 and 1.8 g of protein per Kg of body weight per day [29]. Vitamin D supplementatio n can also help increase muscle mass and should also be considered [29].

Standard dietary supplementation with high-quality protein supplements (>30 g protein/serving) can be helpful, particularly if there is only mild malnutrition. Total parenteral nutrition (TPN) should be considered in patients who are unable to take enteral nutrition. These patients are at higher risk of line-related complications, but this risk is trivial in comparison with those complications that the patient may encounter due to their malnutrition. Enteral nutrition (EN) consists of elemental or semi-elemental feeds delivered to the gut which recently has been shown to be the preferred approach when possible. These data have been borne out in the IBD community where historically patients underwent prolonged usage of TPN for malabsorption and short gut. While studies have shown both TPN and EN are effective at decreasing the risk of surgical complications compared to standard dietary intervention, EN has been shown to be superior to TPN with a number needed to treat of 2 to prevent surgical complications [30]. One downside of EN, however, is that the enteral feeds tend to be foul tasting and difficult to ingest, requiring prolonged placement of a nasogastric tube for up to 4 weeks prior to surgery. TPN tends to be easier to administer, and thus, when given the options, patients will often prefer TPN.

Preoperative immunonutrition is also a useful adjunct in colon and rectal surgery. It is well documented that surgery leads to a state of relative immune suppression in the perioperative period. Immunonutrition usually consists of supplements taken for a week prior to surgery consisting of some combination of arginine, glutamine, branched-chain amino acids, omega-3 fatty acids, and nucleotides. These are designed to target mucosal barrier function, cellular defense, and local and systemic inflammation [31]. A large meta-analysis of immunonutrition showed that while it does not improve mortality, it does decrease the risk of overall complication and infectious complications and shortened hospital stay. The caveat to these data is that when substratified to industry-sponsored vs nonsponsored trials, only the industry sponsored trials demonstrated these benefits [32].

Obesity

Obesity has been shown to increase the risk of almost every type of surgical complication in the colon and rectal surgery patient [33]. Having a plan in place for mitigating the risks of obesity is critical in ensuring optimal patient outcomes. The extremely obese should not be considered for elective surgery without undergoing some manner of weight loss program. This may ultimately include the consideration of bariatric surgery prior to elective colorectal procedures in an attempt to optimize the patient. There are also newer endoluminal approaches to weight loss which carry a lower risk of complications while still achieving modest improvements in both weight loss and correcting the various comorbidities associated with obesity [34]. Morbidly obese patients who can delay their colorectal procedure should be referred to a surgical weight loss team to undergo evaluation.

Many patients will not be able to undergo this long course of evaluation and treatment prior to their surgical intervention. A very low calorie liquid diet has been shown to decrease fat and in particular visceral fat in the preoperative period [35, 36]. By decreasing visceral fat, specifically a surgeon can gain length and reach of bowel. This diet can be particularly helpful in procedures such as low anterior resections and ileal pouch-anal anastomosis where bowel length is crucial. Very low calorie liquid diets usually have the patient consume nutritional shakes that make up less than 800 kcal/day for 1–4 weeks. The amount of fat loss correlates to the time the patient consumes this diet, and it should be done under the direction of a medical or surgical weight loss specialist to ensure that the patients are consuming the appropriate macronutrients.

For those patients who must undergo surgery prior to weight loss, it is important to understand the risks obesity imparts upon the colon and rectal surgery patient. Hernia rates and wound complications are significantly increased in these patients. A minimally invasive approach and off-midline extraction may be helpful in minimizing these wound complications [33, 37]. Surgical site infections are also increased in this population [33]. This may mean that an otherwise uneventful case may still benefit from anastomotic diversion in an attempt to minimize the risk of a leak. These patients may also benefit from drains in their subcutaneous tissues to minimize the risk of infected fat necrosis. Obese patients are also at an increased risk of respiratory and cardiovascular complications from anesthesia [33]. Therefore, it is helpful to include the anesthesia team in your surgical planning and consider prolonged postoperative monitoring for adverse events.

Renal Impairment

Chronic dialysis has been demonstrated to increase the risk of major complications from elective colorectal procedures by at least 2.5-fold and mortality by seven-fold [38]. These patients are particularly difficult to manage postoperatively especially with regard to managing their fluid balance. If these patients present with sepsis, it can be quite difficult to ensure that they maintain the appropriate intravascular volume to support their circulatory system without putting the patient into pulmonary edema. These patients are at a significantly increased risk of both bleeding and VTE [38]. And because of this, it is crucial to carefully manage any postoperative anticoagulation. Patients on dialysis should be managed in conjunction with a nephrologist who should see the patient prior to surgery to ensure that they are optimized. Dialysis should be optimally timed for surgery. It has been shown that an interval of less than 7 hours between dialysis and surgery can lead to postoperative hypotension due to the depleted intravascular state with which these patients undergo surgery [39]. Therefore, it is likely best to dialyze a patient the day prior to surgery to ensure they are undergoing their procedure at euvolemia.

Chronic kidney disease (CKD) not on dialysis also imparts an increased risk of perioperative complications. CKD patients undergoing colorectal resections were more likely to develop cardiovascular complications postoperatively and have a greater than two-fold risk of 30-day mortality [40]. These patients have the potential to be more dysregulated than the dialysis patients depending on their degree of renal impairment. Uremia can lead to a pro-inflammatory state which can lead to an increased risk of atherosclerotic complications as well as infections and bleeding problems. These patients are also often malnourished and volume overloaded, their electrolytes are unbalanced, and they have relative immune suppression. These patients are also often anemic and may benefit from preoperative erythropoietin. When possible their renal function should be optimized as much as possible, and electrolytes should be checked immediately prior to surgery and frequently throughout their procedures.

Preoperative Stoma Marking

Preoperative stoma marking should be arranged for all patients undergoing colon and rectal surgery who may require a stoma at the time of their procedure. A frank conversation about the risks of colostomy or ileostomy is absolutely necessary before attempting bowel surgery. Patients should be aware of the likelihood of this outcome prior to undergoing surgery.

The surgeon may elect to perform their own marking, taking into consideration where the patient’s belt line may fall and then evaluating the abdominal contours. The patient should be evaluated in a variety of positions including sitting and supine. Creases, folds, and surgical scars should be avoided as they are a common site of leakage. Stoma marking should occur medial to the lateral border of the rectus abdominis muscle which can be easily palpated by having the patient sit up part way from the supine position, putting this muscle on tension. Oftentimes, it is necessary to mark multiple locations, either bilaterally or in the upper and lower abdomen depending on the patient’s habitus and the potential for different types of stomas which could be created at the time of surgery.

It is often much more beneficial for the patient to be marked by an enterostomal therapist (EST) or a wound, ostomy, and continence nurse (WOCN). These specialists not only mark the patient prior to surgery, but they help educate the patient on what life with a stoma may be like. They introduce the patients to the equipment and help them gain a familiarity. Oftentimes these nurses will see the patients in the hospital and continue their education prior to and post discharge. For more details on stomas, please refer to Chap. 36 on optimizing stoma function and quality of life.

Preoperative Patient Education

Patient education is a critical part of the enhanced recovery process and of managing expectations of what they will experience during their postop period/hospital stay and at home. Patient education materials should be distributed including the preoperative plan and preparation and what to expect. See Fig. 9.1 for an example. These materials have been demonstrated to help assuage patient’s fears of the unknown and have been demonstrated to decrease length of hospital stay [41].