Epidemiology, pathophysiology and medical management of postoperative ileus in the elderly.

As the population of the Western world ages, the number of major surgical procedures performed in the elderly population will by necessity increase. Within virtually every surgical specialty, studies have shown that patients should not be denied surgery on the basis of chronological age alone. It has recently been recognized that physiological age is far more important within the decision-making algorithm as to whether or not to proceed with major surgery in the septuagenarian and octogenarian populations and beyond. Not unexpectedly, not only the results of these operations, but also the associated morbidities, are similar in older and younger populations. Therefore, it is not surprising that postoperative ileus (POI) affects patients of all ages. POI is a multifactorial condition that is exacerbated by opioid analgesics, bed rest and other conditions that may be rather prevalent in the postoperative elderly patient. Therefore, as major surgical interventions are considered in this population, appropriate assessment and, ideally, correction of any physiological disturbances should be undertaken along with implementation of standardized enhanced recovery protocols. Ideally, through this combined approach, an appreciable impact can be made on reducing POI while controlling postoperative pain and limiting postoperative thromboembolic, cardiopulmonary, cerebral and infectious complications. This article reviews the potential impact of pharmacological agents, laparoscopy and other manoeuvres on POI in the elderly.

What is the definition of "conversion" in laparoscopic colorectal surgery?

BACKGROUND: A web-based survey was conducted among colorectal surgeons who represented members of both SAGES and ASCRS to find out how they define conversion for laparoscopic colorectal surgery. METHODS: Questionnaires were designed based on MCQs, including three parts: surgeon information, different definitions for conversion, and four different clinical scenarios. Surgeons were asked to choose the best definition(s). RESULTS: 325 (28.5%) of 1,140 surgeons, 28.5% responded; approximately half of them were part of private-based practices. Fifty-three percent had more than 10 years experience; 35.9% performed more than 50 laparoscopic colon cases per year, 12% performed more than 25 laparoscopic rectal cases per year, and 60% less than 10. The majority (68.4%) agreed that any incision made earlier than planned is conversion. Whereas 81.4% felt that incision >5 cm is not a conversion, only 53.4% considered incision >10 cm a conversion, and 37% did not. Neither extracorporeal vessel ligation (73.8%), bowel resection (81.2%), anastomosis (77%), or incision made for specimen retrieval (91.1%) was counted as conversion. In clinical case scenarios, 62% found an incision made to facilitate phlegmon dissection after laparoscopically mobilizing the left colon up to and around the splenic flexure to be laparoscopic-assisted. A 10-cm incision required for fistula take down after finishing laparoscopic dissection was defined as conversion (55.6%). A 10-cm incision made for the rectal dissection in rectopexy was described as conversion in 51% and laparoscopic-assisted in 48%. Increasing a 5-12-cm for specimen extraction, 49.3% was declared a laparoscopic-assisted case. CONCLUSIONS: It was considered clear that any incision made earlier than planned a conversion, whereas extra corporeal vessel ligation, bowel resection and anastomosis were not. However, there seem to be many views of conversion regarding incision length, and some clinical situations that might influence outcome among different centers.