Effect of neuromuscular reversal with neostigmine/glycopyrrolate versus sugammadex on postoperative ileus following colorectal surgery

Abstract

Background Postoperative ileus (POI) is a common complication following colorectal surgery and is mediated in part by the cholinergic anti-inflammatory pathway (CAIP). Neostigmine (acetylcholinesterase inhibitor), co-administered with glycopyrrolate, is frequently given for neuromuscular reversal before tracheal extubation and modulates the CAIP. An alternative reversal agent, sugammadex (selective rocuronium or vecuronium binder), acts independently from the CAIP. The aim of our study was to assess the impact of neuromuscular reversal agents used during anaesthesia on gastrointestinal recovery. Methods Three hundred thirty-five patients undergoing elective colorectal surgery at the Royal Adelaide Hospital between January 2019 and December 2021 were retrospectively included. The primary outcome was GI-2, a validated composite measure of time to diet tolerance and passage of stool. Demographics, 30-day complications and length of stay were collected. Univariate and multivariate analyses were performed. Results Two hundred twenty-four (66.9%) patients (129 [57.6%] males and 95 [42.4%] females, median age 64 [19–90] years) received neostigmine/glycopyrrolate and 111 (33.1%) received sugammadex (62 [55.9%] males and 49 [44.1%] females, median age 67 [18–94] years). Sugammadex patients achieved GI-2 sooner after surgery (median 3 (0–10) vs. 3 (0–12) days, p = 0.036), and reduced time to first stool (median 2 (0–10) vs. 3 (0–12) days, p = 0.035). Rates of POI, complications and length of stay were similar. On univariate analysis, POI was associated with smoking history, previous abdominal surgery, colostomy formation, increased opioid use and postoperative hypokalaemia (p < 0.05). POI was associated with increased complications, including anastomotic leak and prolonged hospital stay (p < 0.001). On multivariate analysis, neostigmine, bowel anastomoses and increased postoperative opioid use (p < 0.05) remained predictive of time to GI-2. Conclusions Patients who received sugammadex had a reduced time to achieving first stool and GI-2. Neostigmine use, bowel anastomoses and postoperative opioid use were associated with delayed time to achieving GI-2.

Negative impact of sarcopenia on survival in elderly patients with colorectal cancer receiving surgery: A propensity‑score matched analysis

“…Postoperative complications are often reported to be strongly correlated with both disease recurrence and shorter survival in patients with colorectal cancer (23)(24)(25). Previously, Traeger et al demonstrated sarcopenia had a significant association with postoperative bowel obstruction and complications (11). And Trejo-Avila et al also demonstrated in their meta-analysis that sarcopenia had an association with total postoperative complications, postoperative infection, postoperative cardiopulmonary Relapse-free survival rates of elderly patients with colorectal cancer and with or without elder sarcopenia: 5-year relapse-free survival rate of elderly patients with elder sarcopenia was 78.4%, and that of those without was 91.1%.…”

“…Recently, preoperative sarcopenia has attracted attention as a predictor of postoperative complications and prognosis. In a recent meta-analysis, sarcopenia was prevalent in 37% of colorectal cancer patients, significantly prolonging hospital stay and increasing postoperative complications and mortality rates (10,11). Sarcopenia has also been linked with poor long-term outcomes in patients receiving curative resection for stage 1-3 colorectal cancer (12) and in patients with rectal cancer who underwent preoperative chemoradiotherapy (13,14).…”

The Postoperative Effect of Sugammadex versus Acetylcholinesterase Inhibitors in Colorectal Surgery: An Updated Meta-Analysis

“…The initial database search using the predefined keywords yielded 365 potentially relevant abstracts. Of these, 14 full-text articles were screened for eligibility and finally 5 non-randomized observational studies (1 multi-center prospective and 4 single-center retrospective) comparing the outcome of neuromuscular blockade reversal with sugammadex and acetylcholinesterase inhibitors were included in the qualitative and quantitative data analysis [24][25][26][27][28]. The PRISMA flowchart for the literature search is shown in Figure 1.…”

“…Of the total 1969 patients included (1114 men/855 women), 1137 were assigned to the sugammadex group and 832 were assigned to the acetylcholinesterase inhibitor group (control). Two studies used pyridostigmine as the acetylcholinesterase inhibitor [24,26], and three studies used neostigmine [25,27,28]. Three studies included both malignant and non-malignant cases [25,27,28], while two studies included only patients with colorectal cancer [24,26].…”

“…Two studies used pyridostigmine as the acetylcholinesterase inhibitor [24,26], and three studies used neostigmine [25,27,28]. Three studies included both malignant and non-malignant cases [25,27,28], while two studies included only patients with colorectal cancer [24,26]. The rate of laparoscopic surgery ranged from 20-100% in the sugammadex group to 22-100% in the control group.…”