Top

Langenbeck's Archives of Surgery

Published in:

Open Access 01-01-2014 | Original Article

Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma

Authors: Yitao Jia, Guixing Jin, Shangwei Guo, Bin Gu, Zujian Jin, Xing Gao, Zhongxin Li

Published in: Langenbeck's Archives of Surgery | Issue 1/2014

Abstract

Objective

This study aims to investigate the role of fast-track surgery in preventing the development of postoperative delirium and other complications in elderly patients with colorectal carcinoma.

Methods

A total of 240 elderly patients with colorectal carcinoma (aged ≥70 years) undergoing open colorectal surgery was randomly assigned into two groups, in which the patients were managed perioperatively either with traditional or fast-track approaches. The length of hospital stay (LOS) and time to pass flatus were compared. The incidence of postoperative delirium and other complications were evaluated. Serum interleukin-6 (IL-6) levels were determined before and after surgery.

Results

The LOS was significantly shorter in the fast-track surgery (FTS) group than that in the traditional group. The recovery of bowel movement (as indicated by the time to pass flatus) was faster in the FTS group. The postoperative complications including pulmonary infection, urinary infection and heart failure were significantly less frequent in the FTS group. Notably, the incidence of postoperative delirium was significantly lower in patients with the fast track therapy (4/117, 3.4 %) than with the traditional therapy (15/116, 12.9 %; p = 0.008). The serum IL-6 levels on postoperative days 1, 2, and 3 in patients with the fast-track therapy were significantly lower than those with the traditional therapy (p < 0.001).

Conclusions

Compared to traditional perioperative management, fast-track surgery decreases the LOS, facilitates the recovery of bowel movement, and reduces occurrence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. The lower incidence of delirium is at least partly attributable to the reduced systemic inflammatory response mediated by IL-6.

Wilmore DW, Kehlet H (2001) Management of patients in fast track surgery. BMJ 322:473–466PubMedCrossRef

Kwaan MR, Vogler SA, Sun MY, Sirany AM, Melton GB, Madoff RD, Rothenberger DA (2013) Readmission after colorectal surgery is related to preoperative clinical conditions and major complications. Dis Colon Rectum 56:1087–1092PubMedCrossRef

Pisani MA, Murphy TE, Araujo KL, Van Ness PH (2010) Factors associated with persistent delirium after intensive care unit admission in an older medical patient population. J Crit Care 25:540.e1-7PubMedCrossRef

Tei M, Ikeda M, Haraguchi N, Takemasa I, Mizushima T, Ishii H, Yamamoto H, Sekimoto M, Doki Y, Mori M (2010) Risk factors for postoperative delirium in elderly patients with colorectal cancer. Surg Endosc 24:2135–2139PubMedCrossRef

Koebrugge B, Koek HL, van Wensen RJ, Dautzenberg PL, Bosscha K (2009) Delirium after abdominal surgery at a surgical ward with a high standard of delirium care: incidence, risk factors and outcomes. Dig Surg 26:63–68PubMedCrossRef

Deiner S, Silverstein JH (2009) Postoperative delirium and cognitive dysfunction. Br J Anaesth 103(Suppl 1):i41–i46PubMedCrossRef

Martins S, Fernandes L (2012) Delirium in elderly people: a review. Front Neurol 3:101PubMedCentralPubMedCrossRef

Field RR, Wall MH (2013) Delirium: past, present, and future. Semin Cardiothorac Vasc Anesth 17:170–179PubMedCrossRef

van Munster BC, Bisschop PH, Zwinderman AH, Korevaar JC, Endert E, Wiersinga WJ, van Oosten HE, Goslings JC, de Rooij SE (2010) Cortisol, interleukins and S100B in delirium in the elderly. Brain Cogn 74:18–23PubMedCrossRef

10.

Plaschke K, Fichtenkamm P, Schramm C, Hauth S, Martin E, Verch M, Karck M, Kopitz J (2010) Early postoperative delirium after cardiac surgery was characterized by increased stress levels and inflammatory reaction. Intensive Care Med 36:2081–2089PubMedCrossRef

11.

Holmes C, Cunningham C, Zotova E, Culliford D, Perry VH (2011) Proinflammatory cytokines, sickness behavior, and Alzheimer disease. Neurology 77:212–218PubMedCrossRef

12.

van Munster BC, Korevaar JC, Zwinderman AH, Levi M, Wiersinga WJ, De Rooij SE (2008) Time-course of cytokines during delirium in elderly patients with hip fractures. J Am Geriatr Soc 56:1704–1709PubMedCrossRef

13.

Wang D, Kong Y, Zhong B, Zhou X, Zhou Y (2010) Fast-track surgery improves postoperative recovery in patients with gastric cancer: a randomized comparison with conventional postoperative care. J Gastrointest Surg 14:620–627PubMedCrossRef

14.

Zhao G, Cao S, Cui J (2013) Fast-track surgery improves postoperative clinical recovery and reduces postoperative insulin resistance after esophagectomy for esophageal cancer. Support Care Cancer. doi:10.1007/s00520-013-1979-0

15.

Krenk L, Rasmussen LS, Hansen TB, Bogø S, Søballe K, Kehlet H (2012) Delirium after fast-track hip and knee arthroplasty. Br J Anaesth 108:607–611PubMedCrossRef

16.

Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N. Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci 13:229–242

17.

Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250:187–196PubMedCrossRef

18.

Hatano Y, Narumoto J, Shibata K, Matsuoka T, Taniguchi S, Hata Y, Yamada K, Yaku H, Fukui K (2013) White-matter hyperintensities predict delirium after cardiac surgery. Am J Geriatr Psychiatry 21:938–945PubMedCrossRef

19.

Westhoff D, Witlox J, Koenderman L, Kalisvaart KJ, de Jonghe JF, van Stijn MF, Houdijk AP, Hoogland IC, Maclullich AM, van Westerloo DJ, van de Beek D, Eikelenboom P, van Gool WA (2013) Preoperative cerebrospinal fluid cytokine levels and the risk of postoperative delirium in elderly hip fracture patients. J Neuroinflammation 10:122PubMedCentralPubMedCrossRef

20.

van Munster BC, Zwinderman AH, de Rooij SE (2011) Genetic variations in the interleukin-6 and interleukin-8 genes and the interleukin-6 receptor gene in delirium. Rejuvenation Res 14:425–428PubMedCrossRef

21.

Lemstra AW, Kalisvaart KJ, Vreeswijk R, van Gool WA, Eikelenboom P (2008) Pre-operative inflammatory markers and the risk of postoperative delirium in elderly patients. Int J Geriatr Psychiatry 23:943–948PubMedCrossRef

22.

Wang G, Jiang ZW, Xu J, Gong JF, Bao Y, Xie LF, Li JS (2011) Fast-track rehabilitation program vs conventional care after colorectal resection: a randomized clinical trial. World J Gastroenterol 17:671–676PubMedCrossRef

23.

Wichmann MW, Eben R, Angele MK, Brandenburg F, Goetz AE, Jauch KW (2007) Fast-track rehabilitation in elective colorectal surgery patients: a prospective clinical and immunological single-centre study. ANZ J Surg 77:502–507PubMedCrossRef

24.

Inouye SK (2006) Delirium in older persons. N Engl J Med 354:1157–1165PubMedCrossRef

25.

Patti R, Saitta M, Cusumano G, Termine G, Di Vita G (2011) Risk factors for postoperative delirium after colorectal surgery for carcinoma. Eur J Oncol Nurs 15:519–523PubMedCrossRef

26.

Warrillow SJ, Weinberg L, Parker F, Calzavacca P, Licari E, Aly A, Bagshaw S, Christophi C, Bellomo R (2010) Perioperative fluid prescription, complications and outcomes in major elective open gastrointestinal surgery. Anaesth Intensive Care 38:259–265PubMed

27.

Isfandiaty R, Harimurti K, Setiati S, Roosheroe AG (2012) Incidence and predictors for delirium in hospitalized elderly patients: a retrospective cohort study. Acta Med Indones 44:290–297PubMed

28.

Krenk L, Rasmussen LS, Kehlet H (2010) New insights into the pathophysiology of postoperative cognitive dysfunction. Acta Anaesthesiol Scand 54:951–956PubMedCrossRef

29.

Steiner LA (2011) Postoperative delirium. Part 1: pathophysiology and risk factors. Eur J Anaesthesiol 28:628–636PubMedCrossRef

30.

Voyer P, Richard S, Doucet L, Carmichael PH (2011) Factors associated with delirium severity among older persons with dementia. J Neurosci Nurs 43:62–69PubMedCrossRef

31.

DiFronzo LA, Yamin N, Patel K, O’Connell TX (2003) Benefits of early feeding and early hospital discharge in elderly patients undergoing open colon resection. J Am Coll Surg 197:747–752PubMedCrossRef

32.

Ezhevskaya AA, Mlyavykh SG, Anderson DG (2013) Effects of continuous epidural anesthesia and postoperative epidural analgesia on pain management and stress response in patients undergoing major spinal surgery. Spine 38:1324–1330PubMedCrossRef

33.

Calvo-Soto P, Martínez-Contreras A, Hernández BT, And FP, Vásquez C (2012) Spinal-general anaesthesia decreases neuroendocrine stress response in laparoscopic cholecystectomy. J Int Med Res 40:657–665PubMedCrossRef

34.

Neufeld KJ, Leoutsakos JM, Sieber FE, Wanamaker BL, Gibson Chambers JJ, Rao V, Schretlen DJ, Needham DM (2013) Outcomes of early delirium diagnosis after general anesthesia in the elderly. Anesth Analg 117:471–478PubMedCrossRef

35.

Fredman B, Noga J, Zohar E, Yaretzky A, Jedeikin R (1999) Influence of thiopental and propofol on postoperative cognitive recovery in the elderly patient undergoing general anesthesia. J Clin Anesth 11:635–640PubMedCrossRef

36.

Gaudreau JD, Gagnon P, Roy MA, Harel F, Tremblay A (2007) Opioid medications and longitudinal risk of delirium in hospitalized cancer patients. Cancer 109:2365–2373PubMedCrossRef

37.

Mann C, Pouzeratte Y, Boccara G, Peccoux C, Vergne C, Brunat G, Domergue J, Millat B, Colson P (2000) Comparison of intravenous or epidural patient-controlled analgesia in the elderly after major abdominal surgery. Anesthesiology 92:433–441PubMedCrossRef

38.

Marret E, Remy C, Bonnet F, Postoperative Pain Forum Group (2007) Meta-analysis of epidural analgesia versus parenteral opioid analgesia after colorectal surgery. Br J Surg 94:665–673PubMedCrossRef

39.

Munster BC, Aronica E, Zwinderman AH, Eikelenboom P, Cunningham C, Rooij SE (2011) Neuroinflammation in delirium: a postmortem case–control study. Rejuvenation Res 14:615–622PubMedCrossRef

40.

Beloosesky Y, Hendel D, Weiss A, Hershkovitz A, Grinblat J, Pirotsky A, Barak V (2007) Cytokines and C-reactive protein production in hip-fracture-operated elderly patients. J Gerontol A Biol Sci Med Sci 62:420–426PubMedCrossRef

41.

Murakami M, Hirano T (2012) The pathological and physiological roles of IL-6 amplifier activation. Int J Biol Sci 8:1267–1280PubMedCentralPubMedCrossRef

42.

Miwa H, Kanno H, Munakata S, Akano Y, Taniwaki M, Aozasa K (2000) Induction of chromosomal aberrations and growth-transformation of lymphoblastoid cell lines by inhibition of reactive oxygen species-induced apoptosis with interleukin-6. Lab Invest 80:725–734PubMedCrossRef

43.

Winterhalter M, Brandl K, Rahe-Meyer N, Osthaus A, Hecker H, Hagl C, Adams HA, Piepenbrock S (2008) Endocrine stress response and inflammatory activation during CABG surgery. A randomized trial comparing remifentanil infusion to intermittent fentanyl. Eur J Anaesthesiol 25:326–335PubMedCrossRef

44.

Murphy GS, Szokol JW, Marymont JH, Avram MJ, Vender JS (2007) The effects of morphine and fentanyl on the inflammatory response to cardiopulmonary bypass in patients undergoing elective coronary artery bypass graft surgery. Anesth Analg 104:1334–1342PubMedCrossRef

45.

Parkhill AL, Bidlack JM (2006) Reduction of lipopolysaccharide-induced interleukin-6 production by the kappa opioid U50,488 in a mouse monocyte-like cell line. Int Immunopharmacol 6:1013–1019PubMedCrossRef

46.

Yardeni IZ, Beilin B, Mayburd E, Alcalay Y, Bessler H (2008) Relationship between fentanyl dosage and immune function in the postoperative period. J Opioid Manag 4:27–33PubMed

47.

Dave RS, Khalili K (2010) Morphine treatment of human monocyte-derived macrophages induces differential miRNA and protein expression: impact on inflammation and oxidative stress in the central nervous system. J Cell Biochem 110:834–845PubMedCentralPubMedCrossRef

48.

Banks WA, Kastin AJ, Gutierrez EG (1994) Penetration of interleukin-6 across the murine blood–brain barrier. Neurosci Lett 179:53–56PubMedCrossRef

49.

Threlkeld SW, Lynch JL, Lynch KM, Sadowska GB, Banks WA, Stonestreet BS (2010) Ovine proinflammatory cytokines cross the murine blood–brain barrier by a common saturable transport mechanism. Neuroimmunomodulation 17:405–410PubMedCrossRef

Title: Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma
Authors: Yitao Jia
Guixing Jin
Shangwei Guo
Bin Gu
Zujian Jin
Xing Gao
Zhongxin Li
Publication date: 01-01-2014
Publisher: Springer Berlin Heidelberg
Published in: Langenbeck's Archives of Surgery / Issue 1/2014
Print ISSN: 1435-2443
Electronic ISSN: 1435-2451
DOI: https://doi.org/10.1007/s00423-013-1151-9

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma

Abstract

Objective

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objective

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 1/2014

Changes in the outcomes of severe trauma patients from 15-year experience in a Western European trauma ICU of Emilia Romagna region (1996–2010). A population cross-sectional survey study

Technical feasibility of liver transplantation without cold storage

Laparoscopic ventral hernia repair: is there an optimal mesh fixation technique? A systematic review

Predictors of malignancy in primary aldosteronism

Immunopathogenesis of abdominal sepsis

Clinical review: surgical management of locally advanced and recurrent colorectal cancer