Skip to main content
SpringerLink
Log in
Book cover

The ASCRS Textbook of Colon and Rectal Surgery pp 116–129Cite as

Preoperative Management—Risk Assessment, Medical Evaluation, and Bowel Preparation

  • Reference work entry

Abstract

Preparation of the patient for surgery is a vital component of optimizing recovery after surgery, and must be individually tailored to the medical status of the patient. Patients who undergo colorectal surgery may present in normal health, such as in a young patient undergoing hemorrhoid surgery, or may present in extreme ill health, such as the octogenarian with multiple medical conditions, who has developed perforated diverticulitis. Preoperative assessment and medical intervention are important components of care, and may account for the difference in perioperative mortality noted after abdominal and colorectal surgery between the United States and some European countries.

This is a preview of subscription content, log in via an institution.

Notes

  1. 1.

    Prepared by The Standards Task Force, The American Society of Colon and Rectal Surgeons.

  2. 2.

    Reprinted from The Standards Task Force of the American Society of Colorectal Surgery.66 Copyright 2003. All rights reserved. American Society of Colon and Rectal Surgeons.

  3. 3.

    Prepared by The Standards Task Force, The American Society of Colon and Rectal Surgeons.

  4. 4.

    Reprinted from Dis Colon Rectum 2000;43(9):1193–1200. Copyright 2003. All rights reserved. American Society of Colon and Rectal Surgeons.

References

  1. Kiran RP, Delaney CP, Senagore AJ. Preoperative evaluation and risk assessment scoring. Clin Colorect Surg 2003;16: 75–84.

    Google Scholar 

  2. Bennett‐Guerrero E, Hyam JA, Shaefi S, et al. Comparison of P‐POSSUM risk‐adjusted mortality rates after surgery between patients in the USA and UK. Br J Surg 2003;90:1593–1598.

    Article  PubMed  Google Scholar 

  3. Arvidsson S, Ouchterlony J, Sjostedt L, Svardsudd K. Predicting postoperative adverse events. Clinical efficiency of four general classification systems. The project perioperative risk. Acta Anaesthesiol Scand 1996;40(7):783–791.

    Article  CAS  PubMed  Google Scholar 

  4. Klotz HP, Candinas D, Platz A, et al. Preoperative risk assessment in elective general surgery. Br J Surg 1996;83:1788–1791.

    Article  CAS  PubMed  Google Scholar 

  5. Hartley MN, Sagar PM. The surgeon's ‘gut feeling’ as a predictor of post‐operative outcome. Ann R Coll Surg Engl 1994;76(6 suppl):277–278.

    CAS  PubMed  Google Scholar 

  6. Lawrence VA, Dhanda R, Hilsenbeck SG, et al. Risk of pulmonary complications after elective abdominal surgery. Chest 1996;110(3):744–750.

    Article  CAS  PubMed  Google Scholar 

  7. Mullen JL, Buzby GP, Waldman MT, et al. Prediction of operative morbidity and mortality by preoperative nutritional assessment. Surg Forum 1979;30:80–82.

    CAS  PubMed  Google Scholar 

  8. Greenburg AG, Saik RP, Pridham D. Influence of age on mortality of colon surgery. Am J Surg 1985;150:65–70.

    Article  CAS  PubMed  Google Scholar 

  9. Buzby GP, Mullen JL, Matthews DC, et al. Prognostic nutritional index in gastrointestinal surgery. Am J Surg 1980;139(1):160–167.

    Article  CAS  PubMed  Google Scholar 

  10. Boyd JB, Bradford B Jr, Watne AL. Operative risk factors of colon resection in the elderly. Ann Surg 1980;192(6):743–746.

    Article  CAS  PubMed  Google Scholar 

  11. Cooperman M, Pflug B, Martin EW, et al. Cardiovascular risk factors in patients with peripheral vascular disease. Surgery 1978;84:505–509.

    CAS  PubMed  Google Scholar 

  12. Detsky A, Abrams H, McLaughlin J, et al. Predicting cardiac complications in patients undergoing non‐cardiac surgery. J Gen Intern Med 1986;1:211.

    Article  CAS  PubMed  Google Scholar 

  13. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. New Engl J Med 1977;297:845.

    Article  CAS  PubMed  Google Scholar 

  14. Anonymous. New classification of physical status. Anaesthesiology 1963;24:111.

    Google Scholar 

  15. Keats A. The ASA classification of physical status: a recapitulation. Anaesthesiology 1978;49:233–236.

    Article  CAS  Google Scholar 

  16. Vacanti CJ, Van Houten RJ, Hill RC. A statistical analysis of the relationship of physical status to postoperative mortality in 63,388 cases. Anesth Analg 1970;49:564–566.

    Article  CAS  PubMed  Google Scholar 

  17. Menke H, Klein A, John KD, et al. Predictive value of ASA classification for the assessment of perioperative risk. Int Surg 1993;78:266–270.

    CAS  PubMed  Google Scholar 

  18. Owens WD, Dykes MHM, Gilbert JP, et al. Development of two indices of postoperative morbidity. Surgery 1975;77: 586–592.

    CAS  PubMed  Google Scholar 

  19. Wolters U, Wolf T, Stutzer H, et al. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth 1996;77(2):217–222.

    CAS  PubMed  Google Scholar 

  20. Klotz HP, Candinas D, Platz A, et al. Preoperative risk assessment in elective general surgery. Br J Surg 1996;83:1788–1791.

    Article  CAS  PubMed  Google Scholar 

  21. Mullen JL, Gertner MH, Buzby GP, et al. Implications of malnutrition in the surgical patient. Arch Surg 1979;114: 121–125.

    CAS  PubMed  Google Scholar 

  22. Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE‐acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 1981;9:591–597.

    Article  CAS  PubMed  Google Scholar 

  23. Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification system. Crit Care Med 1985;13: 818–829.

    Article  CAS  PubMed  Google Scholar 

  24. Goffi L, Saba V, Ghiselli R, et al. Preoperative APACHE II and ASA scores in patients having major general surgical operations: prognostic value and potential clinical applications. Eur J Surg 1999;165:730–735.

    Article  CAS  PubMed  Google Scholar 

  25. Koperna T, Semmler D, Marian F. Risk stratification in emergency surgical patients: is the APACHE II score a reliable marker of physiological impairment? Arch Surg 2001;136(1): 55–59.

    Article  CAS  PubMed  Google Scholar 

  26. Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991;100:1619–1636.

    Article  CAS  PubMed  Google Scholar 

  27. Le Gall JR, Loirat P, Alperovitch A, et al. A simplified acute physiology score for ICU patients. Crit Care Med 1984;12: 975–977.

    Article  CAS  PubMed  Google Scholar 

  28. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg 1991;78:355–360.

    Article  CAS  PubMed  Google Scholar 

  29. Senagore AJ, Delaney CP, Duepree HJ, et al. An evaluation of POSSUM and p‐POSSUM scoring systems in assessing outcomes with laparoscopic colectomy. Br J Surg 2003;90: 1280–1284.

    Article  CAS  PubMed  Google Scholar 

  30. Jones DR, Copeland GP, de Cossart L. Comparison of POSSUM with APACHE II for prediction of outcome from a surgical high‐dependency unit. Br J Surg 1992;79:1293–1296.

    Article  CAS  PubMed  Google Scholar 

  31. Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. Br J Surg 1998;85(9):1217–1220.

    CAS  Google Scholar 

  32. Wijesinghe LD, Mahmood T, Scott DJ, et al. Comparison of POSSUM and the Portsmouth predictor equation for predicting death following vascular surgery. Br J Surg 1998;85(2): 209–212.

    Article  CAS  PubMed  Google Scholar 

  33. Kuhan G, Abidia AF, Wijesinghe LD, et al. POSSUM and P‐POSSUM overpredict mortality for carotid endarterectomy. Eur J Vasc Endovasc Surg 2002;23(3):209–211.

    Article  CAS  PubMed  Google Scholar 

  34. Midwinter MJ, Tytherleigh M, Ashley S. Estimation of mortality and morbidity risk in vascular surgery using POSSUM and the Portsmouth predictor equation. Br J Surg 1999;86(4): 471–474.

    Article  CAS  PubMed  Google Scholar 

  35. Tekkis PP, Kocher HM, Bentley AJ, et al. Operative mortality rates among surgeons: comparison of POSSUM and p‐POSSUM scoring systems in gastrointestinal surgery. Dis Colon Rectum 2000;43(11):1528–1532; discussion 1532–1534.

    Article  CAS  PubMed  Google Scholar 

  36. Senagore AJ, Delaney CP, Duepree HJ, Brady K, Fazio VW. An evaluation of POSSUM and p‐POSSUM scoring systems in assessing outcomes with laparoscopic colectomy. Br J Surg 2003;90:1280–1284.

    Article  CAS  PubMed  Google Scholar 

  37. Arvidsson S, Ouchterlony J, Nilsson S, et al. The Gothenburg study of perioperative risk. I. Preoperative findings, postoperative complications. Acta Anaesthesiol Scand 1994;38(7):679–690.

    Article  CAS  PubMed  Google Scholar 

  38. Cullen DJ, Civetta JM, Briggs BA, et al. Therapeutic intervention scoring system: a method for quantitative comparison of patient care. Crit Care Med 1974;2(2):57–60.

    Article  CAS  PubMed  Google Scholar 

  39. Keene AR, Cullen DJ. Therapeutic Intervention Scoring System: update 1983. Crit Care Med 1983;11(1):1–3.

    Article  CAS  PubMed  Google Scholar 

  40. Lemeshow S, Teres D, Pastides H, et al. A method for predicting survival and mortality of ICU patients using objectively derived weights. Crit Care Med 1985;13:519–525.

    Article  CAS  PubMed  Google Scholar 

  41. Matsusue S, Kashihara S, Koizumi S. Prediction of mortality from septic shock in gastrointestinal surgery by probit analysis. Jpn J Surg 1988;18(1):18–22.

    Article  CAS  PubMed  Google Scholar 

  42. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373–383.

    Article  CAS  PubMed  Google Scholar 

  43. Champion HR, Sacco WJ, Carnazzo AJ, et al. Trauma score. Crit Care Med 1981;9(9):672–676.

    Article  CAS  PubMed  Google Scholar 

  44. Haga Y, Ikei S, Wada Y, et al. Estimation of Physiologic Ability and Surgical Stress (E‐PASS) as a new prediction scoring system for postoperative morbidity and mortality following GI surgery. Surg Today 1999;29:219–225.

    Article  CAS  PubMed  Google Scholar 

  45. Haga Y, Wada Y, Takeuchi H, et al. Estimation of physiologic ability and surgical stress (E‐PASS) for a surgical audit in elective digestive surgery. Surgery 2004;135:586–594.

    Article  PubMed  Google Scholar 

  46. Agarwal N, Leighton L, Mandile MA, et al. Outcomes of surgery for colorectal cancer in patients age 80 years and older. Am J Gastroenterol 1990;85:1096–1101.

    CAS  PubMed  Google Scholar 

  47. Ondrula DP, Nelson RL, Prasad ML, et al. Multifactorial index of preoperative risk factors in colon resections. Dis Colon Rectum 1992;35:117–122.

    Article  CAS  PubMed  Google Scholar 

  48. Sagar PM, Hartley MN, Mancey‐Jones B, et al. Comparative audit of colorectal resection with the POSSUM scoring system. Br J Surg 1994;81:1492–1494.

    Article  CAS  PubMed  Google Scholar 

  49. Sagar PM, Hartley MN, Mac Fie J, et al. Comparison of individual surgeon's performance. Risk‐adjusted analysis with POSSUM scoring system. Dis Colon Rectum 1996;39:654–658.

    Article  CAS  PubMed  Google Scholar 

  50. Parker BM, Tetzlaff JE, Litaker DL, Maurer WG. Redefining the preoperative evaluation process and the role of the anesthesiologist. J Clin Anesth 2000;12:350–356.

    Article  CAS  PubMed  Google Scholar 

  51. Arvidsson S. Preparation of adult patients for anaesthesia and surgery. Acta Anaesthesiol Scand 1996;40:962–970.

    Article  CAS  PubMed  Google Scholar 

  52. Badner NH, Craen RA, Paul TL, Doyle JA. Anaesthesia preadmission assessment: a new approach through use of a screening questionnaire. Can J Anaesth 1998;45:87–92.

    Article  CAS  PubMed  Google Scholar 

  53. Mukherjee D, Eagle KA. Perioperative cardiac assessment for noncardiac surgery: eight steps to the best possible outcome. Circulation 2003;107:2771–2774.

    Article  PubMed  Google Scholar 

  54. King MS. Preoperative evaluation. Am Fam Physician 2000;62(2):387–396.

    CAS  PubMed  Google Scholar 

  55. Mancuso CA. Impact of new guidelines on physicians’ ordering of preoperative tests. J Gen Intern Med 1999;14(3):166–172.

    Article  CAS  PubMed  Google Scholar 

  56. Greer AE, Irwin MG. Implementation and evaluation of guidelines for preoperative testing in a tertiary hospital. Anaesth Intensive Care 2000;30:326–330.

    Google Scholar 

  57. Ricciardi G, Angelillo IF, Del Prete U, et al. Routine preoperative investigation. Results of a multicenter survey in Italy. Collaborator Group. Int J Technol Assess Health Care 1998; 14:526–534.

    Article  CAS  PubMed  Google Scholar 

  58. McKee RF, Scott EM. The value of routine preoperative investigations. Ann R Coll Surg 1987;69:160–162.

    CAS  Google Scholar 

  59. Muskett AD, McGreevy JM. Rational preoperative evaluation. Postgrad Med J 1986;62:925–928.

    Article  CAS  PubMed  Google Scholar 

  60. Pedersen T, Eliasen K, Henriksen E. A prospective study of mortality associated with anesthesia and surgery: risk indicators of mortality in hospital. Acta Anaesthesiol Scand 1990;34(3): 176–182.

    Article  CAS  PubMed  Google Scholar 

  61. Roizen M. Preoperative evaluation. Can J Anaesth 1989;36: S13–19.

    Article  CAS  PubMed  Google Scholar 

  62. Macario A, Roizen MF, Thisted RA, Kim S, Orkin FK, Phelps C. Reassessment of preoperative laboratory testing has changed the test‐ordering patterns of physicians. Surg Gynecol Obstet 1992;175:539–547.

    CAS  PubMed  Google Scholar 

  63. Jakobsson A. Routine preoperative electrocardiograms. Lancet 1984;1:972.

    Article  CAS  PubMed  Google Scholar 

  64. Mantha S, Roizen MF, Barnard J, Thisted RA, Ellis JE, Foss J. Relative effectiveness of four preoperative tests for predicting adverse cardiac outcomes after vascular surgery: a meta‐analysis. Anesth Analg 1994;79(3):422–433.

    Article  CAS  PubMed  Google Scholar 

  65. Eagle KA, Berger PB, Calkins H, et al. ACC/AHA guideline update for perioperative cardiovascular evaluation of noncardiac surgery—executive summary: a report of the ACC/AHA task force on practice guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am Coll Cardiol 2002;39:542.

    Article  PubMed  Google Scholar 

  66. The Standards Task Force of the American Society of Colorectal Surgery. Practice parameters for the prevention of venous thromboembolism. Dis Colon Rectum 2000;43:1037–1047.

    Google Scholar 

  67. Wille‐Jorgensen P, Rasmussen MS, Andersen BR, Borly L. Heparin and mechanical methods for thromboprophylaxis in colorectal surgery. Cochrane Database Syst Rev 2003;(4): CD001217.

    Google Scholar 

  68. Brecher ME, Goodnough LT. The rise and fall of preoperative autologous blood donation. Transfusion 2001;41:1459–1462.

    Article  CAS  PubMed  Google Scholar 

  69. Waters JH, Lee SJ, Klein E, et al. Preoperative autologous donation versus cell salvage in the avoidance of allogeneic transfusion in patients undergoing radical retropubic prostatectomy. Anesth Analg 2004;98:537–542.

    Article  PubMed  Google Scholar 

  70. Charpak Y, Blery C, Chastang C, et al. Prospective assessment of a protocol for selective ordering of preoperative chest x‐rays. Can J Anaesth 1988;35:259–264.

    Article  CAS  PubMed  Google Scholar 

  71. Archer C, Levy AR, McGregor M. Value of routine preoperative chest x‐rays: a meta‐analysis. Can J Anaesth 1993;40: 1022–1027.

    Article  CAS  PubMed  Google Scholar 

  72. Evans BA, Wijdicks EF. High‐grade carotid stenosis detected before general surgery: is endarterectomy indicated? Neurology 2001;57:1328–1330.

    CAS  PubMed  Google Scholar 

  73. American Diabetes Association. Clinical Practice Recommendations 1998. Screening for type 2 diabetes (position statement). Diabetes Care 1998;21(suppl 1):S20–22.

    Google Scholar 

  74. Campos AC, Meguid MM. A critical appraisal of the usefulness of perioperative nutritional support. Am J Clin Nutr 1992;55:117–130.

    CAS  PubMed  Google Scholar 

  75. Solla JA, Rothenberger DA. Preoperative bowel preparation. A survey of colon and rectal surgeons. Dis Colon Rectum 1990;33:154–159.

    CAS  Google Scholar 

  76. Rosenberg IL, Graham NG, Dedombal FT, et al. Preparation of the intestine in patients undergoing major large bowel surgery, mainly for neoplasms of the colon and rectum. Br J Surg 1971;58:266–269.

    Article  CAS  PubMed  Google Scholar 

  77. Crapp AR, Tillotson P, Powis SJA, et al. Preparation of the bowel by whole‐gut irrigation. Lancet 1975;ii:1239–1240.

    Article  Google Scholar 

  78. Davis GR, Santa Ana CA, Morawski SG, et al. Development of a lavage solution associated with minimum water and electrolyte absorption or secretion. Gastroenterology 1980; 78:991–995.

    CAS  PubMed  Google Scholar 

  79. Vanner SJ, Mac Donald PH, Paterson WG, et al. A randomized prospective trial comparing oral sodium phosphate with standard polyethylene glycol‐based lavage solution (golytely) in the preparation of patients for colonoscopy. Am J Gastroenterol 1990;85:422–427.

    CAS  PubMed  Google Scholar 

  80. Oliveira L, Wexner SD, Daniel N, et al. Mechanical bowel preparation for elective colorectal surgery. A prospective randomized surgeon‐blinded trial comparing sodium phosphate and polyethylene glycol‐based oral lavage solutions. Dis Colon Rectum 1997;40:585–591.

    Article  CAS  PubMed  Google Scholar 

  81. Lee E, Roberts PL, Taranto R, et al. Inpatient vs. outpatient bowel preparation for elective colorectal surgery. Dis Colon Rectum 1996;39:369–373.

    Article  CAS  PubMed  Google Scholar 

  82. Aronchick CA, Lipshutz WH, Wright SH, et al. A novel tableted purgative for colonoscopic preparation: efficacy and safety comparisons with Colyte and Fleet Phosphosoda. Gastrointest Endosc 2000;52(3):346–352.

    Article  CAS  PubMed  Google Scholar 

  83. Kastenberg D, Chasen R, Choudhary C, et al. Efficacy and safety of sodium phosphate tablets compared with PEG solution in colon cleansing: two identically designed, randomized, controlled, parallel group, multicenter. Gastrointest Endosc 2001; 54(6):705–713.

    Article  CAS  PubMed  Google Scholar 

  84. Vukasin P, Weston L, Beart RW. Oral fleet phosphosoda laxative induced hyperphosphatemia and hypocalcemic tetany in an adult: report of a case. Dis Colon Rectum 1997;40:497–499.

    Article  CAS  PubMed  Google Scholar 

  85. Duthie GS, Foster ME, Price‐Thomas JM, Leaper DJ. Bowel preparation or not for elective colorectal surgery. J R Coll Surg Edinb 1990;35:169–171.

    CAS  PubMed  Google Scholar 

  86. van Geldere D, Fa‐Si‐Oen P, Noach LA, et al. Complications after colorectal surgery without mechanical bowel preparation. J Am Coll Surg 2002;194:40–47.

    Article  PubMed  Google Scholar 

  87. Demetriades D, Murray JA, Chan L, et al. Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma 2001;50: 765–775.

    Article  CAS  PubMed  Google Scholar 

  88. Brownson P, Jenkins SA, Nott D, et al. Mechanical bowel preparation before colorectal surgery: results of a prospective randomized trial. Br J Surg 1992;79:461–462.

    Google Scholar 

  89. Burke P, Mealy K, Gillen P, et al. Requirement for bowel preparation in colorectal surgery. Br J Surg 1994;81:907–910.

    Article  CAS  PubMed  Google Scholar 

  90. Santos JC, Batista J, Sirimarco MT, et al. Prospective randomized trial of mechanical bowel preparation in patients undergoing elective colorectal surgery. Br J Surg 1994;81:1673–1676.

    Article  PubMed  Google Scholar 

  91. Miettinen R, Laitinen ST, Makela JT, Paakkonen ME. Bowel preparation with oral polyethylene glycol electrolyte solution vs. no preparation in elective open colorectal surgery: prospective randomized study. Dis Colon Rectum 2000;43:669–677.

    Article  CAS  PubMed  Google Scholar 

  92. Zmora O, Mahajna A, Bar‐Zakai B, et al. Colon and rectal surgery without mechanical bowel preparation: a randomized, prospective trial. Ann Surg 2003;237:363–367.

    Article  PubMed  Google Scholar 

  93. Guenga KF, Matos D, Castro AA, Atallah AN, Wille‐Jorgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2003;2:CD001544.

    Google Scholar 

  94. Slim K, Vicaut E, Panis Y, et al. Meta‐analysis of randomized clinical trials of colorectal surgery with or without mechanical bowel preparation. Br J Surg 2004;91:1125–1130.

    Article  CAS  PubMed  Google Scholar 

  95. Bartlett JG, Condon RE, Gorbach SL, et al. VA Cooperative Study on Bowel Preparation for Elective Colorectal Operations: impact of oral antibiotic regimen on colonic flora, wound irrigation cultures and bacteriology of septic complications. Ann Surg 1978;188:249–254.

    Article  CAS  PubMed  Google Scholar 

  96. Song F, Glenny AM. Antibiotic prophylaxis in colorectal surgery: a systematic review of randomized controlled trials. Br J Surg 1998;85:1232–1241.

    Article  CAS  PubMed  Google Scholar 

  97. Schoetz DJ, Roberts PL, Murray JJ, Collier JA, Veidenheimer MC. Addition of parenteral cefoxitin to regimen of oral antibiotics for elective colorectal operations. A randomized prospective study. Ann Surg 1990;212:209–212.

    Article  PubMed  Google Scholar 

  98. Danielsen S, Midtvedt T, Giercksky KE. Preventive antibiotics in elective colorectal surgery. Nord Med 1989;104:247–249.

    CAS  PubMed  Google Scholar 

  99. Lewis RT. Oral vs systemic antibiotic prophylaxis in elective colon surgery: a randomized study and meta‐analysis send a message from the 1990s. Can J Surg 2002;45:173–180.

    PubMed  Google Scholar 

  100. Delaney CP, Zutshi M, Senagore AJ, et al. Prospective randomized controlled trial between a pathway of Controlled Rehabilitation with Early Ambulation and Diet (CREAD) and traditional postoperative care after laparotomy and intestinal resection. Dis Colon Rectum 2003;46:851–859.

    Article  PubMed  Google Scholar 

  101. Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson A, Remzi FH. “Fast track” post‐operative management protocol for patients with high comorbidity undergoing complex abdominal and pelvic colorectal surgery. Br J Surg 2001;88:1533–1538.

    Article  CAS  PubMed  Google Scholar 

  102. Basse L, Jakobsen DH, Billesbolle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Ann Surg 2000;232:51–57.

    Article  CAS  PubMed  Google Scholar 

  103. Kiran RP, Delaney CP, Senagore AJ, et al. Prediction and outcome of readmission after intestinal resection. J. Am Coll Surg 2004;198:877–883.

    Article  PubMed  Google Scholar 

Download references

Authors
  1. Conor P. Delaney
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. John M. MacKeigan
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Professor of Surgery, Mayo Clinic College of Medicine, Chairman, Division of Colon and Rectal Surgery, Mayo Clinic Foundation, Rochester, MN, USA

    Bruce G. Wolff MD, FASCRS (Senior Editors) (Senior Editors)

  2. Professor of Surgery, Chief, Section of Colorectal Surgery, Washington University School of Medicine, St. Louis, MO, USA

    James W. Fleshman MD, FASCRS (Senior Editors) (Senior Editors)

  3. Chairman, Department of Colon and Rectal Surgery, Ochsner Clinic Foundation, New Orleans, LA, USA

    David E. Beck MD, FASCRS (Senior Editors) (Senior Editors)

  4. Professor of Surgery, Mayo Clinic College of Medicine, Consultant, Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN, USA

    John H. Pemberton MD, FASCRS (Senior Editors) (Senior Editors)

  5. Chief of Staff, Cleveland Clinic Florida, Weston, FL, USA

    Steven D. Wexner MD, FASCRS (Senior Editors) (Senior Editors)

  6. Victor W. Fazio Chair of Colorectal Surgery, Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA

    James M. Church BSc, MBChB, MMed Sci, FASCRS (Associate Editors) (Associate Editors)

  7. Professor of Surgery, Chief, Section of Colon and Rectal Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA

    Julio Garcia-Aguilar MD, PhD, FASCRS (Associate Editors) (Associate Editors)

  8. Department of Colon and Rectal Surgery, Lahey Clinic, Burlington, MA, USA

    Patricia L. Roberts MD, FASCRS (Associate Editors) (Associate Editors)

  9. Professor of Surgery, Head, Section of Colon and Rectal Surgery, Rush University Medical Center, Chicago, IL, USA

    Theodore J. Saclarides MD, FASCRS (Associate Editors) (Associate Editors)

  10. Division of Colon and Rectal Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA, USA

    Michael J. Stamos MD, FASCRS (Associate Editors) (Associate Editors)

Appendices

Appendix A: Practice Parameters for the Prevention of Venous Thromboembolism

Risk Classification

Low‐risk Patients

The typical low‐risk patient is one undergoing minor surgery who has one or no risk factors. No specific measures are recommended for patients at low risk other than early ambulation. Unprotected, these patients have a 2% chance of calf vein thrombosis and a negligible risk of pulmonary embolus.

Moderate‐risk Patients

The typical moderate‐risk patient is older than 40 years of age, undergoing major abdominal surgery, with no other major risk factors. Moderate‐risk patients can be treated with either intermittent pneumatic compression (IPC) alone or low‐dose unfractionated heparin (LDUH). Moderate‐risk patients have two risk factors. Unprotected, these patients have a 10%–20% risk of calf vein thrombosis, and a 1%–2% chance of a pulmonary embolism.

High‐risk Patients

High‐risk patients have three or four risk factors. The typical high‐risk patient is older than 40 years of age, is having major abdominal surgery, and harbors additional risk factors. High‐risk patients can be treated with LDUH (bid or tid) or low‐molecular‐weight heparin (LMWH), although standard unfractionated heparin seems to be more cost effective. If heparin cannot or should not be used, IPC should be substituted. When heparin has not been started preoperatively, the patient should be reevaluated for postoperative heparin. Unprotected, these patients have a 20%–40% risk of calf vein thrombosis and a 2%–4% risk of pulmonary embolism.

Very High‐risk Patients

A high‐risk patient is upgraded to a highest‐risk category when certain additional risk factors are present. These include a history of thromboembolic events, hypercoagulable states, and possibly malignancy. Assuming no contraindication, highest‐risk patients ideally should receive pharmacologic treatment such as LDUH (bid or tid) or LMWH. Untreated, these patients have a 40%–80% risk of calf vein thrombosis and a 4%–10% risk of pulmonary embolism.

Intuitively, there may be some advantage to a strategy of dual methods, i.e., combining intermittent pneumatic compression with heparin. Several investigators have suggested this. This has been shown to be efficacious for patients undergoing cardia and hip replacement surgery, but thus far there are no published data for colon and rectal surgery patients.

Appendix B: Practice Parameters for Antibiotic Prophylaxis to Prevent Infective Endocarditis or Infective Prosthesis During Colon and Rectal Endoscopy

These parameters are based in part on the recently updated recommendations made by the AHA and the previously published parameters developed by The American Society of Colon and Rectal Surgeons. According to the AHA, the risk for endocarditis is determined by the patient's preexisting cardiac condition and the surgical procedure in question. The major changes in the new AHA guidelines are the following: 1) it was emphasized that invasive procedures are not the cause of most cases of endocarditis; 2) cardiac conditions are stratified by the potential outcome if endocarditis develops; 3) procedures causing bacteremia are more clearly specified; 4) an algorithm for antibiotic prophylaxis for patients with mitral valve prolapse was developed; 5) prophylactic regimens for oral or dental procedures were modified; and 6) prophylactic regimens for genitourinary and gastrointestinal procedures were simplified. The AHA considers lower gastrointestinal endoscopy to be a low‐risk procedure for initiating problematic bacteremia, and The Standards Task Force concurs. The Task Force considered other direct and indirect support for the use of antibiotic prophylaxis in patients with cardiac or other prostheses. It is the consensus of The Standards Task Force that prophylaxis be considered only for the high‐risk groups listed in Table 8‐B.1. The complex nature of individualized patient care does not allow standards to be spelled out for every clinical category.

Table 8‐A.1. Recommendations for VTE prophylaxis by risk classification
Full size table
Table 8‐B.1. Conditions associated with endocarditis (high risk)
Full size table

Rights and permissions

Reprints and permissions

Copyright information

© 2007 Springer Science+Business Media, LLC

About this entry

Cite this entry

Delaney, C.P., MacKeigan, J.M. (2007). Preoperative Management—Risk Assessment, Medical Evaluation, and Bowel Preparation. In: Wolff, B.G., et al. The ASCRS Textbook of Colon and Rectal Surgery. Springer, New York, NY. https://doi.org/10.1007/978-0-387-36374-5_8

Download citation

  • DOI: https://doi.org/10.1007/978-0-387-36374-5_8

  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-0-387-24846-2

  • Online ISBN: 978-0-387-36374-5

  • eBook Packages: MedicineReference Module Medicine

Publish with us

Policies and ethics

Search

Navigation