Reducing ileus after colorectal surgery: A network meta-analysis of therapeutic interventions
James Ashcroft1, Aminder Anthony Singh1, Bhavna Ramachandran2
1Department of Surgery, University of Cambridge, Cambridge, UK.
Background:
Several treatment strategies for avoiding post-operative ileus have been evaluated in randomised controlled trials. This network meta-analysis aimed to explore the relative effectiveness of these different therapeutic interventions on ileus outcome measures.
Methods:
A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing treatments for post-operative ileus following colorectal surgery. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis.
Results:
A total of 48 randomised controlled trials were included in this network meta-analysis reporting on 3614 participants. Early feeding was found to be the best treatment for time to solid diet tolerance and length of hospital stay with a probability of P = 0.96 and P = 0.47, respectively. Early feeding resulted in significantly shorter time to solid diet tolerance (Mean Difference (MD) 58.85 h; 95% Credible Interval (CrI) -73.41, -43.15) and shorter length of hospital stay (MD 2.33 days; CrI -3.51, -1.18) compared to no treatment. Epidural analgesia was ranked best treatment for time to flatus (P = 0.29) and time to stool (P = 0.268). Epidural analgesia resulted in significantly shorter time to flatus (MD -18.88 h; CrI -33.67, -3.44) and shorter time to stool (MD -26.05 h; 95% CrI -66.42, 15.65) compared to no intervention. Gastrograffin was ranked best treatment to avoid the requirement for post-operative nasogastric tube insertion (P = 0.61) however demonstrated limited efficacy (OR 0.50; CrI 0.143, 1.621) compared to no intervention. Nasogastric and nasointestinal tube insertion, probiotics, and acupuncture were found to be least efficacious as interventions to reduce ileus.
Conclusion:
This network meta-analysis identified early feeding as the most efficacious therapeutic intervention to reduce post-operative ileus in patients undergoing colorectal surgery, in addition to highlighting other therapies that require further investigation by high quality study. In patients undergoing colorectal surgery, emphasis should be placed on early feeding as soon as can be appropriately initiated to support the return of gastrointestinal motility.
Insights
Early feeding is the most effective treatment to reduce post-operative ileus after colorectal surgery, significantly shortening hospital stays. Other therapies like epidural analgesia also show benefits for specific recovery markers.
Area of Science:
- Gastroenterology
- Surgical Outcomes
- Evidence-Based Medicine
Background:
- Post-operative ileus (POI) is a common complication following colorectal surgery.
- Various interventions aim to prevent or mitigate POI, but their comparative effectiveness is unclear.
- Randomized controlled trials (RCTs) provide data on different treatment strategies.
Purpose of the Study:
- To conduct a network meta-analysis comparing the relative effectiveness of different interventions for post-operative ileus.
- To evaluate treatments based on key ileus outcome measures in patients undergoing colorectal surgery.
Main Methods:
- Systematic literature review of RCTs comparing POI treatments.
- Bayesian network meta-analysis using Markov chain Monte Carlo methods.
- Simultaneous comparison of direct and indirect treatment effects using random-effects models.
Main Results:
- Early feeding demonstrated the highest efficacy for improving time to solid diet tolerance and reducing length of hospital stay.
- Epidural analgesia was most effective for reducing time to flatus and time to stool.
- Gastrograffin showed limited efficacy for preventing nasogastric tube insertion; nasogastric/nasointestinal tubes, probiotics, and acupuncture were least effective.
Conclusions:
- Early feeding is the most efficacious intervention to reduce post-operative ileus in colorectal surgery patients.
- Emphasis should be placed on initiating early feeding to promote gastrointestinal motility recovery.
- Further high-quality studies are needed to investigate other promising therapies.
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