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Ge B, Zhao H, Lin R, Wang J, Chen Q, Liu L, Huang Q. Influence of gum-chewing on postoperative bowel activity after laparoscopic surgery for gastric cancer: A randomized controlled trial. Medicine (Baltimore) 2017; 96:e6501. [PMID: 28353600 PMCID: PMC5380284 DOI: 10.1097/md.0000000000006501] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 03/02/2017] [Accepted: 03/05/2017] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND In some studies, gum-chewing was demonstrated to have a beneficial effect on resumption of bowel function; however, other contradictory findings in other studies refute the effects of gum-chewing on peristaltic movements and digestive system stimulation. In addition, most previous studies were after colorectal or gynecology surgery, whereas few reports focused on the effect of gum-chewing after gastrectomy. The aim of this randomized controlled trial was to assess the effectiveness of gum-chewing on postoperative bowel function in patients who had undergone laparoscopic gastrectomy. METHODS From March 2014 to March 2016, 75 patients with gastric cancer received elective laparoscopic surgery in Shanghai Tongji hospital and were postoperatively randomly divided into 2 groups: 38 in a gum-chewing (Gum) group and 37 in a control (No gum) group. The patients in the Gum group chewed sugarless gum 3 times daily, each time for at least 15 minutes, until the day of postoperative exhaust defecation. RESULTS The mean time to first flatus (83.4 ± 35.6 vs. 79.2 ± 24.2 hours; P = 0.554) and the mean time to first defecation (125.7 ± 41.2 vs. 115.4 ± 34.2 hours; P = 0.192) were no different between the no gum and Gum groups. There was also no significant difference in the incidence of postoperative ileus (P = 0.896) and postoperative hospital stay (P = 0.109) between the 2 groups. The postoperative pain score at 48 hours (P = 0.032) in the Gum group was significantly higher than in the no gum group. There was no significant difference between the 2 groups in regards to patient demographics, comorbidities, duration of surgery, complications, and nausea/vomiting score. CONCLUSION Gum-chewing after laparoscopic gastrectomy did not hasten the return of gastrointestinal function. In addition, gum-chewing may increase patient pain on the second postoperative day.
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Affiliation(s)
- Bujun Ge
- Department of General Surgery, Tongji Hospital
| | - Hongmei Zhao
- Department of Neurology, East Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Rui Lin
- Department of General Surgery, Tongji Hospital
| | | | | | - Liming Liu
- Department of General Surgery, Tongji Hospital
| | - Qi Huang
- Department of General Surgery, Tongji Hospital
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Yang Y, Zuo HQ, Li Z, Qin YZ, Mo XW, Huang MW, Lai H, Wu LC, Chen JS. Comparison of efficacy of simo decoction and acupuncture or chewing gum alone on postoperative ileus in colorectal cancer resection: a randomized trial. Sci Rep 2017; 7:37826. [PMID: 28102199 PMCID: PMC5244388 DOI: 10.1038/srep37826] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 11/02/2016] [Indexed: 01/21/2023] Open
Abstract
To compared the ability of chewing gum or simo decoction (SMD) and acupuncture to reduce incidence of postoperative ileus (POI) after colorectal cancer resection, patients with colorectal cancer undergoing open or laparoscopic resection were randomized to receive SMD and acupuncture (n = 196), chewing gum alone (n = 197) or no intervention (n = 197) starting on postoperative day 1 and continuing for 5 consecutive days. Patients treated with SMD and acupuncture experienced significantly shorter hospital stay, shorter time to first flatus and shorter time to defecation than patients in the other groups (all P < 0.05). Incidence of grade I and II complications was also significantly lower in patients treated with SMD and acupuncture. Patients who chewed gum were similar to those who received no intervention in terms of hospital stay, incidence of complications, and time to first bowel motion, flatus, and defecation (all P > 0.05). The combination of SMD and acupuncture may reduce the incidence of POI and shorten hospital stay for patients with colorectal cancer after resection. In contrast, chewing gum does not appear to affect recovery of bowel function or hospital stay, though it may benefit patients who undergo open resection. (Clinicaltrials.gov registration number: NCT02813278).
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Affiliation(s)
- Yang Yang
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, PR China
| | - Hong-Qun Zuo
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, PR China
| | - Zhao Li
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, PR China
| | - Yu-Zhou Qin
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, PR China
| | - Xian-Wei Mo
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, PR China
| | - Ming-Wei Huang
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, PR China
| | - Hao Lai
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, PR China
| | - Liu-Cheng Wu
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, PR China
| | - Jian-Si Chen
- Department of Gastrointestinal Surgery, Affiliated Tumor Hospital of Guangxi Medical University, Nanning, PR China
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Wen ZJ, Wang WT, Mei BB, Wu C, Shen MF. Gum chewing for promoting intestinal function recovery after colorectal cancer surgery: A meta-analysis. Shijie Huaren Xiaohua Zazhi 2017; 25:147-158. [DOI: 10.11569/wcjd.v25.i2.147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the effect of gum chewing on intestinal function recovery after colorectal cancer surgery.
METHODS we searched databases such as PubMed and EMBASE for randomized controlled trials that evaluated the effect of gum chewing on the intestinal function recovery after colorectal cancer surgery published till June 2016. RevMan5.3 analysis software was used for data consolidation.
RESULTS A total of 22 studies involving 2285 patients were included in this study. Meta-analysis results showed that gum chewing after operation produced a significant difference in times to first flatus [-0.57, 95% confidence interval (CI): -0.74-(-0.41)], defecation [-0.62, 95%CI: -1.06-(-0.18)], bowel movement [-0.44, 95%CI: -0.72-(-0.16)], gastrin level (29.92, 95%CI: 15.65-44.19), feeding [-1.33, 95%CI: -2.19-(-0.48)], hospital stay [-1.33, 95%CI: -2.19-(-0.48)], and ileus (0.33, 95%CI: 0.14-0.78), although no significant difference was found in postoperative nausea (0.90, 95%CI: 0.59-1.39), vomiting (0.91, 95%CI: 0.59-1.39), abdominal distention (0.62, 95%CI: 0.36-1.06), or mortality (2.25, 95%CI: 0.63-8.09).
CONCLUSION Gum chewing after colorectal cancer surgery may accelerate intestinal function recovery, but does not reduce postoperative complications. Larger rigorous studies are needed for better understanding of the role of gum chewing.
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Abstract
PURPOSE OF REVIEW The current review summarizes different aspects of assessment of gastrointestinal function and provides a practical approach to management of adult patients with gastrointestinal dysfunction in the ICU. RECENT FINDINGS Different ways to define gastrointestinal failure have been used in the past. Recently, the term 'acute gastrointestinal injury (AGI)' has been proposed to specifically describe gastrointestinal dysfunction as a part of multiple organ dysfunction syndrome. Possible pathophysiological mechanisms and different aspects in assessment of gastrointestinal function in adult ICU patients are presented. Currently, there is no single marker that could reliably describe gastrointestinal dysfunction. Therefore, monitoring and management is still based on complex assessment of different gastrointestinal symptoms and feeding intolerance, even though this approach includes a large amount of subjectivity. The possible role of biomarkers (citrulline, enterohormones, etc.) and additional parameters like intra-abdominal pressure remains to be clarified. SUMMARY Defining gastrointestinal failure remains challenging but broad consensus needs to be reached and disseminated soon to allow conduct of interventional studies. A systematic approach to management of gastrointestinal problems is recommended.
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Flores-Funes D, Campillo-Soto Á, Pellicer-Franco E, Aguayo-Albasini JL. Uso de café, chicle y gastrografín en el manejo del íleo postoperatorio: revisión de la evidencia actual. Cir Esp 2016; 94:495-501. [DOI: 10.1016/j.ciresp.2016.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 05/06/2016] [Accepted: 05/30/2016] [Indexed: 12/15/2022]
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Abstract
Postoperative ileus (POI) is a major focus of concern for surgeons because it increases duration of hospitalization, cost of care, and postoperative morbidity. The definition of POI is relatively consensual albeit with a variable definition of interval to resolution ranging from 2 to 7 days for different authors. This variation, however, leads to non-reproducibility of studies and difficulties in interpreting the results. Certain risk factors for POI, such as male gender, advanced age and major blood loss, have been repeatedly described in the literature. Understanding of the pathophysiology of POI has helped combat and prevent its occurrence. But despite preventive and therapeutic efforts arising from such knowledge, 10 to 30% of patients still develop POI after abdominal surgery. In France, pharmacological prevention is limited by the unavailability of effective drugs. Perioperative nutrition is very important, as well as limitation of preoperative fasting to 6 hours for solid food and 2 hours for liquids, and virtually no fasting in the postoperative period. Coffee and chewing gum also play a preventive role for POI. The advent of laparoscopy has led to a significant improvement in the recovery of gastrointestinal function. Enhanced recovery programs, grouping together all measures for prevention or cure of POI by addressing the mechanisms of POI, has reduced the duration of hospitalization, morbidity and interval to resumption of transit.
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Gero D, Gié O, Hübner M, Demartines N, Hahnloser D. Postoperative ileus: in search of an international consensus on definition, diagnosis, and treatment. Langenbecks Arch Surg 2016; 402:149-158. [PMID: 27488952 DOI: 10.1007/s00423-016-1485-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 07/17/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE Postoperative ileus (POI) is a frequent complication after abdominal surgery; nonetheless, it remains poorly defined. Our aim was to achieve an international consensus among leading colorectal surgeons on definition, prevention, and treatment of POI. METHODS Thirty-five experts from five continents participated in a three-round Delphi process. Round 1 contained open-ended questions on POI and postoperative nausea and vomiting (PONV). Round 2 included closed-ended questions. Round 3 measured agreement on a 5-point Likert scale. Consensus was defined when items were rated as agree or strongly agree by at least 70 % of the experts. RESULTS Experts reached following consensus: POI is a temporary inhibition (86 %) of gastrointestinal motility after surgical intervention due to non-mechanical causes (89 %) and prevents sufficient oral intake (96 %). Abdominal distension/tenderness are the most relevant clinical signs (71 %). Nasogastric tube placement is not mandatory (78 %) but can be removed without previous clamping (81 %)/gastrointestinal contrast study (100 %). Preventive measures are recommended to decrease the risk of POI (96 %): narcotic sparing analgesia (89 %) and fluid optimization (74 %). Treatment of POI should include stimulation of ambulation (96 %) and stop of opioids (74 %). Total parenteral nutrition is recommended from the 7th day without sufficient oral intake (81 %). There was no consensus on the ranking of POI's symptoms, on the imaging modality of choice for the diagnosis of POI, neither on the difference between POI and PONV. CONCLUSIONS This Delphi study achieved consensus on the definition, relevant clinical signs, prevention, treatment, and supportive care of POI. Areas of non-consensus were identified (necessity and modality of radiologic imaging to establish the diagnosis, difference between POI and PONV), giving opportunity for further research.
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Affiliation(s)
- Daniel Gero
- Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Olivier Gié
- Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Martin Hübner
- Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Nicolas Demartines
- Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Dieter Hahnloser
- Department of Visceral Surgery, University Hospital CHUV, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland.
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Normal Values and Clinical Use of Bedside Sonographic Assessment of Postoperative Gastric Emptying: A Prospective Cohort Study. Dis Colon Rectum 2016; 59:758-65. [PMID: 27384094 DOI: 10.1097/dcr.0000000000000637] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND GI dysfunction is common after abdominal surgery. However, assessment and diagnosis currently lack objective measurement. OBJECTIVE The purpose of this study was to evaluate the feasibility and clinical use of bedside sonographic assessment of gastric emptying by measuring the time to complete emptying of a standard volume of ingested water in patients after colorectal surgery. DESIGN This was a prospective cohort study. SETTINGS The study was conducted at a single tertiary institution in Sydney. PATIENTS Healthy volunteers (n = 30) were studied to establish a reference range. Gastric emptying was then measured in patients (n = 39) before and after colorectal surgery. INTERVENTION Assessment of gastric emptying was performed on days 1 to 4 by measuring antral cross-sectional area every 10 minutes after ingestion of 250 mL of water. MAIN OUTCOME MEASURES The time to complete emptying of water was used as a surrogate measure of gastric emptying. Information concerning postoperative outcomes, GI symptoms, and recovery was also recorded. RESULTS The median time to complete emptying of water for healthy volunteers was 20 minutes (range, 10-40 minutes). The study protocol was completed in 30 of 39 patients. The time to complete emptying of water on day 2 had the best discriminatory power to identify patients with ileus (sensitivity, 85.71%; specificity, 82.61%). Gastric emptying was normal in 20 of 30 (67%) patients, with only 1 case of ileus (false negative). These patients had less nausea (p = 0.0003), earlier intake of solid diet (p = 0.001), and shorter hospital stay (p = 0.040) compared with patients with abnormal gastric emptying. LIMITATIONS Ultrasound is operator dependent with a learning curve. CONCLUSIONS Bedside sonographic assessment of gastric emptying is feasible and reliable. Assessment of antral contents with a single ultrasound 40 minutes after ingestion of water enables classification of patients into those with normal and abnormal gastric emptying. When performed on postoperative day 2, it has good sensitivity/specificity for discriminating patients with ileus.
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Vilz TO, Pantelis D, Lingohr P, Fimmers R, Esmann A, Randau T, Kalff JC, Coenen M, Wehner S. SmartPill® as an objective parameter for determination of severity and duration of postoperative ileus: study protocol of a prospective, two-arm, open-label trial (the PIDuSA study). BMJ Open 2016; 6:e011014. [PMID: 27401360 PMCID: PMC4947765 DOI: 10.1136/bmjopen-2015-011014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Postoperative ileus (POI) is a frequent complication after abdominal surgery (AS). Until today, neither a prophylaxis nor an evidence-based therapy exists. This originates from the absence of objective parameters evaluating the severity and duration of POI resulting in clinical trials of modest quality. The SmartPill(®), a capsule which frequently measures pH value, temperature and intraluminal pressure after swallowing, offers an elegant option for analysing gastrointestinal (GI) transit times and smooth muscle activity in vivo. As the use in patients in the first months after AS is not covered by the marketing authorisation, we aim to investigate the safety and feasibility of the SmartPill(®) immediately after surgery. Additionally, we analyse the influence of prokinetics and laxatives as well as standardised physiotherapy on postoperative bowel contractility, as scientific evidence of its effects is still lacking. METHODS AND ANALYSIS The PIDuSA study is a prospective, single-centre, two-arm, open-label trial. The SmartPill(®) will be applied to 55 patients undergoing AS having a high risk for POI and 10 patients undergoing extra-abdominal surgery rarely developing POI. The primary objective is the safety of the SmartPill(®) in patients after surgery on the basis of adverse device effects/serious adverse device effects (ADE/SADE). The sample size suggests that events with a probability of 3% could be seen with a certainty of 80% for at least once in the sample. Secondary objective is the analysis of postoperative intestinal activity in the GI tract in both groups. Furthermore, clinical signs of bowel motility disorders will be correlated to the data measured by the SmartPill(®) to evaluate its significance as an objective parameter for assessing POI severity. Additionally, effects of prokinetics, laxatives and physiotherapy on postoperative peristaltic activity recorded by the SmartPill(®) will be analysed. ETHICS AND DISSEMINATION The protocol was approved by the federal authority (94.1.05-5660-8976) and the local ethics committee (092/14-MPG). Findings will be disseminated through publications and conference presentations. TRIAL REGISTRATION NUMBER NCT02329912; Pre-results.
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Affiliation(s)
- Tim O Vilz
- Department of Surgery, University of Bonn, Bonn, Germany
| | | | | | - Rolf Fimmers
- Clinical Study Core Unit, Study Center Bonn (SZB), University of Bonn, Bonn, Germany
- Institute of Medical Biometrics, Informatics and Epidemiology, Study Center Bonn, University of Bonn, Bonn, Germany
| | - Anke Esmann
- Department of Surgery, University of Bonn, Bonn, Germany
| | - Thomas Randau
- Department of Orthopedics and Trauma Surgery, University of Bonn, Bonn, Germany
| | - Jörg C Kalff
- Department of Surgery, University of Bonn, Bonn, Germany
| | - Martin Coenen
- Clinical Study Core Unit, Study Center Bonn (SZB), University of Bonn, Bonn, Germany
- Institute of Clinical Chemistry and Clinical Pharmacology, University of Bonn, Bonn, Germany
| | - Sven Wehner
- Department of Surgery, University of Bonn, Bonn, Germany
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Weijs TJ, Berkelmans GHK, Nieuwenhuijzen GAP, Dolmans ACP, Kouwenhoven EA, Rosman C, Ruurda JP, van Workum F, van Det MJ, Silva Corten LC, van Hillegersberg R, Luyer MDP. Immediate Postoperative Oral Nutrition Following Esophagectomy: A Multicenter Clinical Trial. Ann Thorac Surg 2016; 102:1141-8. [PMID: 27324526 DOI: 10.1016/j.athoracsur.2016.04.067] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 03/01/2016] [Accepted: 04/20/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Immediate start of oral intake is beneficial following colorectal surgery. However, following esophagectomy the safety and feasibility of immediate oral intake is unclear, thus these patients are still kept nil by mouth. This study therefore aimed to determine the feasibility and safety of oral nutrition immediately after esophagectomy. METHODS A multicenter, prospective trial was conducted in 3 referral centers between August 2013 and May 2014, including 50 patients undergoing a minimally invasive esophagectomy. Oral nutrition was started postoperatively immediately (clear liquids on postoperative day [POD] 0, liquid nutrition on POD 1 to 6, solid food from POD 7). Nonoral enteral nutrition was started when <50% of caloric need was met on postoperative day POD 5 or when oral intake was impossible. A comparison was made with a retrospective cohort (n = 50) with a per-protocol delayed start of oral intake until POD 4 to 7. RESULTS The median caloric intake at POD 5 was 58% of required. In 38% of the patients nonoral nutrition was started, mainly due to complications (36%). The pneumonia rate was 28% following immediate oral intake and 40% following delayed oral intake (p = 0.202). The aspiration pneumonia rate was 4% in both groups. The anastomotic leakage rate was 14% after immediate oral intake versus 24% following delayed oral intake (p = 0.202). The 90-day mortality rate was 2% in both groups. Hospital stay and intensive care unit stay were significantly shorter following immediate oral intake. CONCLUSIONS Immediate start of oral nutrition following esophagectomy seems to be feasible and does not increase complications compared to a retrospective cohort and literature. However, if complications arise an alternative nutritional route is required. This explorative study shows that a randomized controlled trial is needed.
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Affiliation(s)
- Teus J Weijs
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | | | | | | | - Camiel Rosman
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frans van Workum
- Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT Hospital, Almelo, the Netherlands
| | | | | | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
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Gong J, Xie Z, Zhang T, Gu L, Yao W, Guo Z, Li Y, Lu N, Zhu W, Li N, Li J. Randomised clinical trial: prucalopride, a colonic pro-motility agent, reduces the duration of post-operative ileus after elective gastrointestinal surgery. Aliment Pharmacol Ther 2016; 43:778-89. [PMID: 26880227 DOI: 10.1111/apt.13557] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 09/22/2015] [Accepted: 01/22/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous studies have shown that recovery of colonic transit is a major determinant of post-operative ileus and clinical recovery after gastrointestinal surgery. Prucalopride is a highly selective 5-hydroxytryptamine receptor-4 agonist with colonic pro-motility effects. AIM To evaluate the effect and safety of prucalopride on post-operative ileus and surgical outcomes after elective gastrointestinal surgery. METHODS In this phase II randomised clinical trial, 110 patients undergoing elective gastrointestinal surgery were randomised to either oral prucalopride (2 mg/day) (n = 55) or placebo (n = 55). Intervention was started 24 h after surgery and stopped after defecation or maximally at 7 days. The primary outcome was time to defecation. Secondary outcomes included time to first passage of flatus, tolerance of solid food, nasogastric tube reinsertion, post-operative length of stay, hospital readmission, overall cost, time to walk independently, surgical complications and inflammatory parameters. RESULTS Patients who received prucalopride had a shorter time to defecation (65.0 vs. 94.5 h, P = 0.001), passage of flatus (53.0 vs. 73.0 h, P < 0.001), and post-operative length of stay (7.0 vs. 8.0 days, P = 0.001) than controls. The number of patients with prolonged ileus (>5 days) (16.4% vs. 34.5%, P = 0.026) and the C-reactive protein level on post-operative day 5 (35.67 vs. 59.07 mg/L, P = 0.040) were lower in the prucalopride group. There was no significant difference in post-operative Clavien-Dindo grade III and IV complications (P = 0.606) between the groups. CONCLUSION Prucalopride is a safe and effective treatment to reduce post-operative ileus and systemic inflammation without affecting post-operative complications in patients undergoing elective gastrointestinal surgery. ClinicalTrials.gov: NCT02004652.
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Affiliation(s)
- J Gong
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Z Xie
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - T Zhang
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - L Gu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - W Yao
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Z Guo
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Y Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - N Lu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - W Zhu
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - N Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - J Li
- Department of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Abstract
An enhanced recovery after surgery strategy will be increasingly adopted in the era of value-based care. The various elements in each enhanced recovery after surgery protocol are likely to add value to the overall patient surgical journey. Although the evidence varies considerably based on type of surgery and patient group, the team-based approach of care should be universally applied to patient care. This article provides an overview of up-to-date techniques and methodology for enhanced recovery, including an overview of value-based care, delivery, and the evidence base supporting enhanced recovery after surgery.
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Affiliation(s)
- Arvind Chandrakantan
- Department of Anesthesiology, Stony Brook Medicine, HSC Level 4, Room 060, Stony Brook, NY 11794-8480, USA
| | - Tong Joo Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook University, HSC Level 4, Room 060, Stony Brook, NY 11794-8480, USA.
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Karmali S, Jenkins N, Sciusco A, John J, Haddad F, Ackland G. Randomized controlled trial of vagal modulation by sham feeding in elective non-gastrointestinal (orthopaedic) surgery. Br J Anaesth 2015; 115:727-35. [DOI: 10.1093/bja/aev283] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2015] [Indexed: 01/11/2023] Open
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You XM, Mo XS, Ma L, Zhong JH, Qin HG, Lu Z, Xiang BD, Wu FX, Zhao XH, Tang J, Pang YH, Chen J, Li LQ. Randomized Clinical Trial Comparing Efficacy of Simo Decoction and Acupuncture or Chewing Gum Alone on Postoperative Ileus in Patients With Hepatocellular Carcinoma After Hepatectomy. Medicine (Baltimore) 2015; 94:e1968. [PMID: 26559269 PMCID: PMC4912263 DOI: 10.1097/md.0000000000001968] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
To compare the efficacy of simo decoction (SMD) combined with acupuncture at the tsusanli acupoint or chewing gum alone for treating postoperative ileus in patients with hepatocellular carcinoma (HCC) after hepatectomy.In postoperative ileus, a frequent complication following hepatectomy, bowel function recovery is delayed, which increases length of hospital stay. Studies suggest that chewing gum may reduce postoperative ileus; SMD and acupuncture at the tsusanli acupoint have long been used in China to promote bowel movement.Patients with primary HCC undergoing hepatectomy between January 2015 and August 2015 were randomized to receive SMD and acupuncture (n = 55) or chewing gum (n = 53) or no intervention (n = 54) starting on postoperative day 1 and continuing for 6 consecutive days or until flatus. Primary endpoints were occurrence of postoperative ileus and length of hospital stay; secondary endpoints were surgical complications.Groups treated with SMD and acupuncture or with chewing gum experienced significantly shorter time to first peristalsis, flatus, and defecation than the no-intervention group (all P < 0.05). Hospital stay was significantly shorter in the combined SMD and acupuncture group (mean 14.0 d, SD 4.9) than in the no-intervention group (mean 16.5 d, SD 6.8; P = 0.014), while length of stay was similar between the chewing gum group (mean 14.7, SD 6.2) and the no-intervention group (P = 0.147). Incidence of grades I and II complications was slightly lower in both intervention groups than in the no-intervention group.The combination of SMD and acupuncture may reduce incidence of postoperative ileus and shorten hospital stay in HCC patients after hepatectomy. Chewing gum may also reduce incidence of ileus but does not appear to affect hospital stay. (Clinicaltrials.gov registration number: NCT02438436.).
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Affiliation(s)
- Xue-Mei You
- From the Hepatobiliary Surgery Department, Affiliated Tumor Hospital of Guangxi Medical University (XMY, XSM, LM, JHZ, HGQ, ZL, BDX, FXW, YHP, JT, XHZ, JC, LQL); and Guangxi Liver Cancer Diagnosis and Treatment Engineering and Technology Research Center, Nanning, PR China (XMY, LM, JHZ, BDX, FXW, YHP, JT, XHZ, JC, LQL)
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Peters EG, De Jonge WJ, Smeets BJJ, Luyer MDP. The contribution of mast cells to postoperative ileus in experimental and clinical studies. Neurogastroenterol Motil 2015; 27:743-9. [PMID: 26011782 DOI: 10.1111/nmo.12579] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 04/07/2015] [Indexed: 02/08/2023]
Abstract
The persistent phase of postoperative ileus (POI) is mediated by inflammatory activation of the resident myeloid immune cell population in the gut wall, likely elicited by neurogenic activation. Mast cells are thought to play a critical role in this inflammatory response and involvement of mast cells in POI has been investigated and described thoroughly in experimental studies. Intestinal manipulation (IM) leads to degranulation of mast cells, resulting in an increase in mast cell proteases in peritoneal fluid and gut tissue. The inflammatory infiltrate formed in the intestinal wall thereby impairs gastrointestinal motility. In the clinical study by Berdun et al., the experimentally known association between mast cell degranulation and delayed motility is shown in a clinical setting. These findings are important and open up therapeutic opportunities to reduce or prevent POI. In this mini-review, the role of mast cells in POI is discussed. Furthermore, an update is given on the involvement of the inflammatory response in POI and potential therapeutic strategies.
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Affiliation(s)
- E G Peters
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands.,Tytgat Institute for Liver and Intestinal Research, Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - W J De Jonge
- Tytgat Institute for Liver and Intestinal Research, Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - B J J Smeets
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - M D P Luyer
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
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Willemze RA, Luyer MD, Buurman WA, de Jonge WJ. Neural reflex pathways in intestinal inflammation: hypotheses to viable therapy. Nat Rev Gastroenterol Hepatol 2015; 12:353-62. [PMID: 25963513 DOI: 10.1038/nrgastro.2015.56] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Studies in neuroscience and immunology have clarified much of the anatomical and cellular basis for bidirectional interactions between the nervous and immune systems. As with other organs, intestinal immune responses and the development of immunity seems to be modulated by neural reflexes. Sympathetic immune modulation and reflexes are well described, and in the past decade the parasympathetic efferent vagus nerve has been added to this immune-regulation network. This system, designated 'the inflammatory reflex', comprises an afferent arm that senses inflammation and an efferent arm that inhibits innate immune responses. Intervention in this system as an innovative principle is currently being tested in pioneering trials of vagus nerve stimulation using implantable devices to treat IBD. Patients benefit from this treatment, but some of the working mechanisms remain to be established, for instance, treatment is effective despite the vagus nerve not always directly innervating the inflamed tissue. In this Review, we will focus on the direct neuronal regulatory mechanisms of immunity in the intestine, taking into account current advances regarding the innervation of the spleen and lymphoid organs, with a focus on the potential for treatment in IBD and other gastrointestinal pathologies.
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Affiliation(s)
- Rose A Willemze
- Department of Gastroenterology, Tytgat Institute for Liver and Intestinal Research, Academic Medical Centre, Meibergdreef 69, 1105BK Amsterdam, Netherlands
| | - Misha D Luyer
- Department of Surgery, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ, Eindhoven, Netherlands
| | - Wim A Buurman
- School for Mental Health and Neuroscience, Health and Nutrition, 6200 MD, Maastricht University, Netherlands
| | - Wouter J de Jonge
- Department of Gastroenterology, Tytgat Institute for Liver and Intestinal Research, Academic Medical Centre, Meibergdreef 69, 1105BK Amsterdam, Netherlands
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Peters EG, Smeets BJJ, Dekkers M, Buise MD, de Jonge WJ, Slooter GD, Reilingh TSDV, Wegdam JA, Nieuwenhuijzen GAP, Rutten HJT, de Hingh IHJT, Hiligsmann M, Buurman WA, Luyer MDP. The effects of stimulation of the autonomic nervous system via perioperative nutrition on postoperative ileus and anastomotic leakage following colorectal surgery (SANICS II trial): a study protocol for a double-blind randomized controlled trial. Trials 2015; 16:20. [PMID: 25623276 PMCID: PMC4318130 DOI: 10.1186/s13063-014-0532-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/19/2014] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Postoperative ileus and anastomotic leakage are important complications following colorectal surgery associated with short-term morbidity and mortality. Previous experimental and preclinical studies have shown that a short intervention with enriched enteral nutrition dampens inflammation via stimulation of the autonomic nervous system and thereby reduces postoperative ileus. Furthermore, early administration of enteral nutrition reduced anastomotic leakage. This study will investigate the effect of nutritional stimulation of the autonomic nervous system just before, during and early after colorectal surgery on inflammation, postoperative ileus and anastomotic leakage. METHODS/DESIGN This multicenter, prospective, double-blind, randomized controlled trial will include 280 patients undergoing colorectal surgery. All patients will receive a selfmigrating nasojejunal tube that will be connected to a specially designed blinded tubing system. Patients will be allocated either to the intervention group, receiving perioperative nutrition, or to the control group, receiving no nutrition. The primary endpoint is postoperative ileus. Secondary endpoints include anastomotic leakage, local and systemic inflammation, (aspiration) pneumonia, surgical complications classified according to Clavien-Dindo, quality of life, gut barrier integrity and time until functional recovery. Furthermore, a cost-effectiveness analysis will be performed. DISCUSSION Activation of the autonomic nervous system via perioperative enteral feeding is expected to dampen the local and systemic inflammatory response. Consequently, postoperative ileus will be reduced as well as anastomotic leakage. The present study is the first to investigate the effects of enriched nutrition given shortly before, during and after surgery in a clinical setting. TRIAL REGISTRATION ClinicalTrials.gov: NCT02175979 - date of registration: 25 June 2014. Dutch Trial Registry: NTR4670 - date of registration: 1 August 2014.
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Affiliation(s)
- Emmeline G Peters
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands. .,Academic Medical Center, Tytgat Institute for Intestinal and Liver Research, Department of Gastroenterology, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands.
| | - Boudewijn J J Smeets
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Marloes Dekkers
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Marc D Buise
- Department of Anesthesiology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Wouter J de Jonge
- Academic Medical Center, Tytgat Institute for Intestinal and Liver Research, Department of Gastroenterology, Meibergdreef 69-71, 1105 BK, Amsterdam, The Netherlands.
| | - Gerrit D Slooter
- Department of Surgery, Maxima Medical Center, De Run 4600, 5504 DB, Veldhoven, The Netherlands.
| | | | - Johannes A Wegdam
- Department of Surgery, Elkerliek Hospital, Wesselmanlaan 25, 5707 HA, Helmond, The Netherlands.
| | - Grard A P Nieuwenhuijzen
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Mickael Hiligsmann
- Department of Health Services Research, Maastricht University, Duboisdomein 30, 6229 GT, Maastricht, The Netherlands.
| | - Wim A Buurman
- Institute MHeNS, Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
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