Postoperative ileus: mechanisms and future directions for research

Effect of different carbon dioxide (CO2) insufflation for laparoscopic colorectal surgery in elderly patients: A randomized controlled trial

BACKGROUND

Evidence suggests that dry CO2 insufflation during laparoscopic colorectal surgery results in greater structural injury to the peritoneum and longer hospital stay than the use of warm, humidified CO2. We aimed to test the hypothesis that warm, humidified CO2 insufflation could reduce postoperative pain and improve recovery in laparoscopic colorectal surgery.

METHODS

One hundred fifty elderly patients undergoing laparoscopic colorectal surgery under general anesthesia from May 2017 to October 2018 were randomly divided into 3 groups. The primary outcomes were resting pain, cough pain, and consumption of sufentanil at 2, 4, 6, 12, 24, and 48 hours postoperatively. Quality of visual image, hemodynamic changes, esophageal temperature, mean skin temperature, mean body temperature, recovery time, days to first flatus and solid food intake, shivering, incidence of postoperative ileus, length of hospital stay, surgical site infections, patients and surgeon satisfaction scores, adverse events, prothrombin time, activated partial thromboplastin time, and thrombin time were recorded.

RESULTS

Group CE patients were associated with significantly higher early postoperative cough pain and sufentanil consumption than the other 2 groups (P < .05). Compared with group CE, patients in both groups WH and CF had significantly reduced intraoperative hypothermia, recovery time of PACU, days to first flatus and solid food intake, and length of hospital stay, while the satisfaction scores of both patients and surgeon were significantly higher (P < .05). Prothrombin time, activated partial thromboplastin time, and thrombin time were significantly higher in group CE from 60 minutes after pneumoperitoneum to the end of pneumoperitoneum than the other 2 groups (P < .05). The number of patients with a shivering grade of 0 was significantly lower and grade of 3 was significantly higher in group CE than in the other 2 groups (P < .05).

CONCLUSION

Use of either warm, humidified CO2 insufflations or 20°C, 0% relative humidity CO2 combined with forced-air warmer set to 38°C during insufflations can both reduce intraoperative hypothermia, dysfunction of coagulation, early postoperative cough pain, sufentanil consumption, days to first flatus, solid food intake, and length of hospital stay.

Opioid-free shoulder arthroplasty: a prospective study of a novel clinical care pathway

BACKGROUND

Opioid therapy has been a cornerstone of perioperative pain control for decades in the United States, despite our increased understanding of the morbidity and mortality linked to opioids. The purpose of this study is to explore the safety, efficacy, and feasibility of an entirely opioid-free perioperative pathway in patients undergoing elective shoulder arthroplasty.

METHODS

Thirty-five patients undergoing elective total shoulder arthroplasty with a mean age of 71 (range, 50-87) years elected into a comprehensive opioid-free, multimodal pain management protocol. Opioid use was completely eliminated for all points in the perioperative period including during regional and general anesthesia. Data were collected regarding patient-reported pain, opioid consumption in the perioperative period, postoperative delirium, nausea, constipation, and falls.

RESULTS

Pain level at the primary outcome point of 24 hours or discharge was rated at 2.5 on the numeric rating scale. Stable, low pain scores were demonstrated at all time points postoperatively. Low rates of nausea, falls, and constipation were reported. Only 1 patient required "rescue" opioid medications during the in-patient stay, and an additional patient was given a low-dose opioid prescription at the 2-week postoperative appointment.

CONCLUSIONS

An opioid-free, multimodal pain management pathway is a safe and effective option in properly selected patients undergoing shoulder arthroplasty with a very low risk of requiring rescue opioids. This study is the first such study to present a surgical protocol entirely free of opioids at all portions of the patient care pathway.

Development of a postoperative ileus risk assessment scale: identification of intraoperative opioid exposure as a significant predictor after spinal surgery

OBJECTIVE

Postoperative ileus (POI) is associated with abdominal pain, nausea, vomiting, and delayed mobilization that in turn lead to diminished patient satisfaction, increased hospital length of stay (LOS), and increased healthcare costs. In this study, the authors developed a risk assessment scale to predict the likelihood of developing POI following spinal surgery.

METHODS

The authors undertook a retrospective review of a prospectively maintained registry of consecutive patients who underwent arthrodesis/fusion surgeries between May 2013 and December 2017. They extracted clinical information, including cumulative intraoperative and postoperative opioid doses using standardized converted morphine milligram equivalent (MME) values. Univariate and multivariate analyses were performed and several categorical and continuous variables were evaluated in a binary logistic regression model built with backward elimination to assess for independent predictors. A points-based prediction model was developed and validated to determine the risk of POI.

RESULTS

A total of 334 patients who underwent spinal fusion surgeries were included. Fifty-six patients (16.8%) developed POI, more frequently in those who underwent long-segment surgeries compared to short-segment surgeries (33.3% vs 10.4%; p < 0.001). POI was associated with an increased LOS when compared with patients who did not develop POI (8.0 ± 4.5 days vs 4.4 ± 2.4 days; p < 0.01). The incidences of liver disease (16% vs 3.7%; p = 0.01) and substance abuse history (12.0% vs 3.2%; p = 0.04) were higher in POI patients than non-POI patients undergoing short-segment surgeries. While the incidences of preoperative opioid intake (p = 0.23) and cumulative 24-hour (87.7 MME vs 73.2 MME; p = 0.08) and 72-hour (225.6 MME vs 221.4 MME; p = 0.87) postoperative opioid administration were not different, remifentanil (3059.3 µg vs 1821.5 µg; p < 0.01) and overall intraoperative opioid (326.7 MME vs 201.7 MME; p < 0.01) dosing were increased in the POI group. The authors derived a multivariate model based on the 5 most significant factors predictive of POI (number of surgical levels, intraoperative MME, liver disease, age, and history of substance abuse) and calculated relative POI risks using a derived 32-point system.

CONCLUSIONS

Intraoperative opioid administration, incorporated in a comprehensive risk assessment scale, represents an early and potentially modifiable predictor of POI. These data indicate that potential preventive strategies, implemented as part of enhanced recovery after surgery protocols, could be instituted in the preoperative phase of care to reduce POI incidence.

The risk factors for postoperative ileus following posterior thoraco-lumbar spinal fusion surgery

OBJECTIVE

Postoperative ileus (PI) is a common complication following posterior thoraco-lumbar spinal fusion surgery. It usually slows patient's recovery and increases postoperative morbidity. However, the risk factors associated with PI in patients undergoing posterior thoraco-lumbar spinal fusion surgery are still unclear. The purpose of this study is to investigate the potential risk factors for PI in those patients.

PATIENTS AND METHODS

A prospective study was conducted and 426 patients received posterior thoraco-lumbar spinal fusion surgery between March 2017 and February 2018 were included in this study. The associations between different clinical factors and PI were analyzed. A logistic regression analysis was performed to detect independent risk factors for PI. The cut-off value, sensitivity and specificity of these independent factors were calculated by receiver operating characteristic (ROC) curve.

RESULTS

In this study, 8.2% (35/426) of these patients were identified with PI. The average length of postoperative hospital stay was 12.54 ± 6.06 days in patients with PI compared with 8.91 ± 3.81 days in patients without PI (P =  0.001). These results indicated that surgical duration, PLIF approach, blood loss and length of postoperative diet restriction were potential risk factors for PI in patients with thoraco-lumbar spinal fusion surgery. The cut-off values of surgical duration, blood loss and length of postoperative diet restriction were 4.375 h, 750 ml and 9.5 h, respectively. Combination of surgical duration, PLIF approach, blood loss and length of postoperative diet restriction has the highest predictive value for PI (AUC = 0.910, P <  0.001).

CONCLUSION

Based on the study, surgical duration, PLIF approach, blood loss and length of postoperative diet restriction were the independent risk factors for PI in patients with posterior thoraco-lumbar spinal fusion surgery. Combined those factors has the highest risk for developing PI.

X-ray evaluation of intestinal dysmotility induced by Eimeria pragensis infection in C57BL/6 mice

This study was conducted to elucidate the intestinal dysmotility during coccidiosis. C57BL/6 male mice at seven weeks of age were inoculated with Eimeria pragensis sporulated oocysts (100 to 1,000 oocysts). The intestinal motility was evaluated by observing discharging time of barium sulfate (Ba₂SO₄) after oral administration (WITT: the whole intestinal transit time). The exact location of the dysmotility was analyzed by intermittent barium gastrography. Upper intestinal dysmotility was evaluated by charcoal propulsion study. Additionally, the occurrence of dysmotility was observed at different post-infection times (4, 7, and 14 days post-infection (d.p.i.)) and in infection-dose dependent manner (100, 300, and 1,000 oocysts). As the E. pragensis infected mice had significantly lower feed intake compared to the control group, we designed a feed apprehension study to evaluate the effect of low feed intake on the intestinal dysmotility. The WITT of infected mice at 7 d.p.i. was significantly longer (6 hr) than the uninfected mice (2.5 hr). Intestinal dysmotility was observed in the small intestine, caecum, and colorectum in the infected mice. Charcoal propulsion was slower in infected group (reaching to 40.4% of the whole small intestine) compared to control group (68.0%). The dysmotility was observed at the beginning of the patent period (7 d.p.i.) and subsided as the patency ended (14 d.p.i.). Mice with lower feed intake appeared to have similar intestinal motility as control mice. In summary, this study revealed the evidence of intestinal hypomotility during E. pragensis infection.

Prolonged Postoperative Ileus Significantly Increases the Cost of Inpatient Stay for Patients Undergoing Elective Colorectal Surgery: Results of a Multivariate Analysis of Prospective Data at a Single Institution

BACKGROUND

Prolonged postoperative ileus is a common major complication after abdominal surgery. Retrospective data suggest that ileus doubles the cost of inpatient stay. However, current economic impact data are based on retrospective studies that rely on clinical coding to diagnose ileus.

OBJECTIVE

The aim of this study was to determine the economic burden of ileus for patients undergoing elective colorectal surgery.

DESIGN

Economic data were audited from a prospective database of patients who underwent surgery at Auckland City Hospital between September 2012 and June 2014.

SETTINGS

Auckland City Hospital is a large tertiary referral center, using an enhanced recovery after surgery protocol.

PATIENTS

Patients were prospectively diagnosed with prolonged postoperative ileus using a standardized definition.

MAIN OUTCOME MEASURES

The cost of inpatient stay was analyzed with regard to patient demographics and operative and postoperative factors. A multivariate analysis was performed to determine the cost of ileus when accounting for other significant covariates.

RESULTS

Economic data were attained from 325 patients, and 88 patients (27%) developed ileus. The median inpatient cost (New Zealand dollars) for patients with prolonged ileus, including complication rates and length of stay, was $27,981 (interquartile range= $20,198 to $42,174) compared with $16,317 (interquartile range = $10,620 to $23,722) for other patients, a 71% increase in cost (p < 0.005). Ileus increased all associated healthcare costs, including medical/nursing care, radiology, medication, laboratory costs, and allied health (p < 0.05). Multivariate analysis showed that ileus remained a significant financial burden (p < 0.005) when considering rates of major complications and length of stay.

LIMITATIONS

This is a single-institution study, which may impact the generalizability of our results.

CONCLUSIONS

Prolonged ileus causes a substantial financial burden on the healthcare system, in addition to greater complication rates and length of stay in these patients. This is the first study to assess the financial impact of prolonged ileus, diagnosed prospectively using a standardized definition. See Video Abstract at http://links.lww.com/DCR/A825.

Mechanism of Electroacupuncture on Postoperative Ileus Induced by Surgical Stress in Rats

Objectives: Acupuncture has been used for treating gastrointestinal (GI) disorders such as postoperative nausea and vomiting. Electroacupuncture (EA) accelerates GI transit following surgery and ameliorates postoperative ileus (POI) to restore colonic transit (CT); however, the mechanisms of this EA-induced restoration remain unclear. The aims of this study were to show CT following surgery and the effects of EA at ST 36 on POI induced by surgical stress (SS) in 45 conscious, male Sprague-Dawley rats. Materials and Methods: An operation was performed in each rat, setting a cannula into the cecum to connect the proximal colon to inject markers. On the day after surgery, 20 metal radiopaque markers were administered to the proximal colon of each rat. These markers were visible throughout the GI tract on soft X-ray immediately after administration and up to 240 minutes afterward. The rats were divided into 5 groups with 9 rats in each group: (1) SS; (2) 5 days post surgery (POST-5D); (3) SS + phentolamine; (4) EA alone; and (5) EA + atropine. The EA was performed at ST 36 for 20 minutes at a frequency of 10 Hz and agents were administered in the appropriate groups before markers were administered and measurements were taken. Measurements were performed the day after surgery except in the POST 5-D group. CT was calculated by the geometric center on the images showing the CT for each rat. Results: CT after surgery was delayed significantly and phentolamine accelerated CT. EA restored CT following surgery and atropine abolished the effect of EA on CT. Conclusions: The current study demonstrated that surgery induced a delay in CT through the sympathetic pathway via α-adrenoreceptors; CT was restored by EA. These results suggest that EA can be used to treat POI through mediation of the autonomic nervous system.

Postoperative Ileus

Postoperative ileus (POI) is a common complication following colon and rectal surgery, with reported incidence ranging from 10 to 30%. It can lead to increased morbidity, cost, and length of stay. Although definitions vary considerably in the literature, in its pathologic form, it can be characterized by a temporary inhibition of gastrointestinal motility after surgical intervention due to nonmechanical causes that prevents sufficient oral intake. Various risk factors for development of POI have been identified including increasing age, American Society of Anesthesiologists scores 3 to 4, open approach, operative difficulty, operative duration more than 3 hours, bowel handling, drop in hematocrit or need for a transfusion, increasing crystalloid administration, and delayed mobilization. While treatment is expectant and supportive, significant investigations into strategies to mitigate development of POI or shorten its duration have been undertaken with mixed results. There is significant evidence to suggest that a minimally invasive approach and multimodal pain regimens reduce the development of POI. The beneficial effect of chewing gum, alvimopan, and enhanced recovery after surgery protocols may decrease development of POI in selected groups of patients who undergo elective colorectal surgery, and shorten time to return of bowel function, but overall, the data remain inconclusive.

System-Wide Improvement for Transitions After Ileostomy Surgery: Can Intensive Monitoring of Protocol Compliance Decrease Readmissions? A Randomized Trial

BACKGROUND

Hospital readmission is common after ileostomy formation and frequently associated with dehydration.

OBJECTIVE

This study was conducted to evaluate a previously published intervention to prevent dehydration and readmission.

DESIGN

This is a randomized controlled trial.

SETTING

This study was conducted in 3 hospitals within a single health care system.

PATIENTS

Patients undergoing elective or nonelective ileostomy as part of their operative procedure were selected.

INTERVENTION

Surgeons, advanced practice providers, inpatient and outpatient nurses, and wound ostomy continence nurses participated in a robust ileostomy education and monitoring program (Education Program for Prevention of Ileostomy Complications) based on the published intervention. After informed consent, patients were randomly assigned to a postoperative compliance surveillance and prompting strategy that was directed toward the care team, versus usual care.

OUTCOME MEASURES

Unplanned hospital readmission within 30 days of discharge, readmission for dehydration, acute renal failure, estimated direct costs, and patient satisfaction were the primary outcomes measured.

RESULTS

One hundred patients with an ileostomy were randomly assigned. The most common indications were rectal cancer (n = 26) and ulcerative colitis (n = 21), and 12 were emergency procedures. Although intervention patients had better postdischarge phone follow-up (90% vs 72%; p = 0.025) and were more likely to receive outpatient intravenous fluids (25% vs 6%; p = 0.008), they had similar overall hospital readmissions (20.4% vs 19.6%; p = 1.0), readmissions for dehydration (8.2% vs 5.9%; p = 0.71), and acute renal failure events (10.2% vs 3.9%; p = 0.26). Multivariable analysis found that weekend discharges to home were significantly associated with readmission (OR, 4.5 (95% CI, 1.2-16.9); p = 0.03). Direct costs and patient satisfaction were similar.

LIMITATIONS

This study was limited by the heterogeneous patient population and by the potential effect of the intervention on providers taking care of patients randomly assigned to usual care.

CONCLUSIONS

A surveillance strategy to ensure compliance with an ileostomy education program tracked patients more closely and was cost neutral, but did not result in decreased hospital readmissions compared with usual care. See Video Abstract at http://links.lww.com/DCR/A812.

Daikenchuto accelerates the recovery from prolonged postoperative ileus after open abdominal surgery: a subgroup analysis of three randomized controlled trials

Purpose

Prolonged postoperative ileus (POI) is a common complication after open abdominal surgery (OAS). Daikenchuto (DKT), a traditional Japanese medicine that peripherally stimulates the neurogenic pathway, is used to treat prolonged POI in Japan. To analyze whether DKT accelerates the recovery from prolonged POI after OAS, we conducted a secondary analysis of three multicenter randomized controlled trials (RCTs).

Methods

A secondary analysis of the three RCTs supported by the Japanese Foundation for Multidisciplinary Treatment of Cancer (project numbers 39-0902, 40-1001, 42-1002) assessing the effect of DKT on prolonged POI in patients who had undergone OAS for colon, liver, or gastric cancer was performed. The subgroup included 410 patients with no bowel movement (BM) before the first diet, a DKT group (n = 214), and a placebo group (n = 196). Patients received either 5 g DKT or a placebo orally, three times a day. The primary endpoint was defined as the time from the end of surgery to the first bowel movement (FBM). A sensitivity analysis was also performed on the age, body mass index and dosage as subgroup analyses.

Results

The primary endpoint was significantly accelerated in the DKT group compared with the placebo group (p = 0.004; hazard ratio 1.337). The median time to the FBM was 113.8 h in the placebo group and 99.1 h in the DKT treatment group.

Conclusions

The subgroup analysis showed that DKT significantly accelerated the recovery from prolonged POI following OAS.

Trial registration number

UMIN000026292.

Colonic Electromechanical Abnormalities Underlying Post-operative Ileus: A Systematic and Critical Review

Post-operative ileus (POI) is an inevitable consequence of major abdominal surgery, and may be prolonged in up to 30% of patients. Ileus is commonly presumed to result from paralysis of the GI tract, though there is little direct evidence to support this view. The aim of this review is to systematically search and critically review the literature investigating post-operative colonic electrical and mechanical activity. MEDLINE and Embase databases were systematically searched for articles investigating post-operative colonic motor or electrical activity in human patients. Nineteen original articles investigating post-operative colonic motor or electrical activity were identified. Most studies have used low-resolution techniques, with intermittent recordings of colonic motility. Numerous studies have shown that colonic electrical and motor activity does not cease routinely following surgery, but is of abnormal character for 3–6 days following laparotomy. One recent high-resolution manometry study identified hyperactive cyclic motor patterns occurring in the distal colon on the first post-operative day. Low-resolution studies have shown colonic slow waves are not inhibited by surgery, and are present even in the immediate post-operative period. Recovery of normal motility appears to occur in a proximal to distal direction and is temporally correlated with the clinical return of bowel function. No studies have investigated motility specifically in prolonged POI. Future studies should use high-resolution techniques to accurately characterise abnormalities in electrical and mechanical function underlying POI, and correlate these changes with clinical recovery of bowel function.

Neuronal regulation of intestinal immune functions in health and disease

BACKGROUND

Nerve-mucosa interactions control various elements of gastrointestinal functions, including mucosal host defense, gut barrier function, and epithelial cell growth and differentiation. In both intestinal and extra-intestinal diseases, alterations of autonomic nerve activity have been observed to be concurrent with the disease course, such as in inflammatory and functional bowel diseases, and neurodegenerative diseases. This is relevant as the extrinsic autonomic nervous system is increasingly recognized to modulate gut inflammatory responses. The molecular and cellular mechanisms through which the extrinsic and intrinsic nerve pathways may regulate digestive mucosal functions have been investigated in several pre-clinical and clinical studies.

PURPOSE

The present review focuses on the involvement of neural pathways in gastrointestinal disease, and addresses the current strategies to intervene with neuronal pathway as a means of treatment.

Electrical Stimulation and Recovery of Gastrointestinal Function Following Surgery: A Systematic Review

OBJECTIVES

Postoperative ileus occurs in approximately 5-15% of patients following major abdominal surgery, and poses a substantial clinical and economic burden. Electrical stimulation has been proposed as a means to aid postoperative gastrointestinal (GI) recovery, but no methods have entered routine clinical practice. A systematic review was undertaken to assess electrical stimulation techniques and to evaluate their clinical efficacy in order to identify promising areas for future research.

MATERIALS AND METHODS

Literature was searched using MEDLINE, EMBASE, Google Scholar and by assessing relevant clinical trial databases. Studies investigating the use of electrical stimulation for postoperative GI recovery were included, regardless of methods used or outcomes measured. A critical review was constructed encompassing all included studies and evaluating and synthesizing stimulation techniques, protocols, and clinical outcomes.

RESULTS

A broad range of neuromodulation strategies and protocols were identified and assessed. Improved postoperative GI recovery following electrical stimulation was reported by 55% of studies (10/18), most commonly those assessing transcutaneous electrical nerve stimulation and electroacupuncture therapy (7/10). Several studies reported shorter time to first flatus and stool, shorter duration of hospital stay, and reduced postoperative pain. However, inconsistent reporting and limitations in trial design were common, compromising a definitive determination of electrical stimulation efficacy.

CONCLUSIONS

Electrical stimulation appears to be a promising methodology to aid postoperative GI recovery, but greater attention to mechanisms of action and clinical trial quality is necessary for progress. Future research should also aim to apply validated and standardized gut recovery outcomes and consistent neuromodulation methodologies.

The association between bowel obstruction and the management of cholelithiasis and cholecystitis in elderly patients: A population-based cohort study

AIMS

This study aimed to evaluate the risk of bowel events among elderly patients treated using only PTGBD (Percutaneous Gallbladder Drainage), or a cholecystectomy on its own, or PTGBD combined with a subsequent cholecystectomy.

METHODS

A retrospective population-based cohort study was conducted with newly diagnosed cholelithiasis and cholecystitis patients who had no bowel obstruction history and were aged over 65 years during the period of January 1, 2000 to December 31, 2010. These patients were placed into 3 separate study cohorts; PTGBD alone, cholecystectomy alone and PTGBD with subsequent laparoscopic cholecystectomy, with the cohort frequencies matched by age and gender. We defined the index date as the time of the initial cholelithiasis and cholecystitis diagnosis date and began observation and suspended follow-up when the patient had either withdrawn from their health insurance, developed bowel obstruction or reached the date of December 31, 2011.

RESULTS

The incidences of bowel obstruction were 24.6, 19.2 and 13.6 per 1000 person-years for PTGBD cohort, cholecystectomy cohort and PTGBD respectively, with a subsequent laparoscopic cholecystectomy cohort. Compared with the PTGBD cohort, (which was adjusted for age, gender, CCI score and laparotomy history), the hazard ratio of bowel obstruction was 0.77 (95% Confidence Interval (CI) = 0.59-1.00) and 0.57 (95% CI = 0.43-0.76) for the cholecystectomy cohort and PTGBD with a subsequent laparoscopic cholecystectomy cohort respectively.

CONCLUSION

For treatment of cholelithiasis and cholecystitis in elderly patients, PTGBD with a subsequent cholecystectomy could benefit patients by providing a lower risk of ileus or intestinal obstruction.

Goal-directed fluid therapy does not reduce postoperative ileus in gastrointestinal surgery: A meta-analysis of randomized controlled trials

BACKGROUND

Perioperative goal-directed fluid therapy (GDFT) aiming to maintain individual fluid balance based on sensitive parameters was prevalent in major surgery, especially in enhanced recovery after surgery (ERAS) pathway. This meta-analysis was conducted for the purpose of evaluating whether GDFT impacts on occurrence of postoperative ileus and whether its application is worthwhile in gastrointestinal surgery.

METHODS

A systematic search of RCTs compared GDFT with other fluid management in patients undergoing gastrointestinal surgery from the PubMed, Web of Science, Embase, Cochrane Library databases was implemented. The primary outcome is incidence of postoperative ileus. Other outcome measures were length of hospital stay (LOS), postoperative morbidity and mortality. Subgroup analysis was planed a prior to verify the definite role of GDFT.

RESULTS

12 trials consisted of 1836 patients were included in the final analysis. GDFT did not influence the occurrence of postoperative ileus (relative risk, RR 0.71, 95% confidence interval, CI 0.47-1.07, P = .10), with moderate heterogeneity (I = 29%, P = .16). No difference was found between GDFT and control groups in LOS (mean difference -0.17 days, 95% CI -0.73 to 0.39, P = .55), total complication rate (RR 0.92, 95% CI 0.81-1.05, P = .23), and 30-day mortality (RR 0.91, 95% CI 0.47-1.75, P = .77). In other secondary outcomes, only wound infection rate was lower in the GDFT group (RR 0.68, 95% CI 0.50-0.93, P = .02). When performed subgroup analysis, GDFT was superior in reduction ileus only when compared with standard therapy or in those outside ERAS.

CONCLUSIONS

It is possible that GDFT dose not affect the occurrence of postoperative ileus in gastrointestinal surgery. It scarcely influences postoperative morbidity and mortality as well. However, lower incidence of ileus is observed in GDFT group either outside ERAS or compared with standard fluid therapy. Probably, GDFT may not be necessary in the ERAS pathway or if a hybrid approach is adopted.

Ethacrynic acid decreases expression of proinflammatory intestinal wall cytokines and ameliorates gastrointestinal stasis in murine postoperative ileus

OBJECTIVES

Several compounds characterized by an olefin linkage conjugated to a carbonyl group have anti-inflammatory properties. The diuretic ethacrynic acid (EA) is a compound of this type. Herein, we tested the hypothesis that ethacrynic acid can modulate the development of ileus after bowel manipulation.

METHODS

Groups (n=9) of male C57Bl/6 mice underwent surgical manipulation of the small intestine using a pair of cotton-tipped applicators (MAN). Control animals (CONT) did not undergo any surgical intervention or receive treatment. MAN mice were pre- and post-treated with four intraperitoneal doses of phosphate buffered saline (PBS), EA1 (1mg/kg per dose), or EA10 (10mg/kg per dose). Gastrointestinal transit of non-absorbable FITC-labeled dextran was assessed by gavaging the mice with the tracer 24h after operation and assessing FD70 concentration 120 min later in the bowel contents from the stomach, 10 equally long segments of small intestine, cecum, and two equally long segments of colon. The geometric center for the tracer was calculated for each animal. Expression of interleukin-6 (IL-6) and inducible nitric oxide synthase (iNOS) transcripts in the ileal muscularis propria was assessed using semiquantitative reverse transcriptase-polymerase chain reaction.

RESULTS

In control animals, the mean (±SE) geometric center for the transit marker was 9.89±0.47, whereas it was 4.59±0.59 for PBS-treated animals (p<0.05 vs CONT). The geometric center for pre- post treatment with low (1mg/kg) and high (10mg/kg) doses of ethacrynic acid were 7.23±0.97 and 5.15±0.57, respectively. Compared to PBS, treatment with ethacrynic acid (1mg/kg) significantly decreased manipulation-induced IL-6 and iNOS mRNA expression in the wall of the small bowel.

CONCLUSIONS

Pre- and post-treatment with ethacrynic acid ameliorates ileus and modulates inflammation in the gut wall induced by bowel manipulation.

Nonsteroidal anti-inflammatory drugs reduce the time to recovery of gut function after elective colorectal surgery: a systematic review and meta-analysis

AIM

Postoperative ileus causes significant patient morbidity after abdominal surgery. Some evidence suggests nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce time to gut recovery, but there has not been a meta-analysis to assess their efficacy. This systematic review and meta-analysis aimed to determine the benefit of NSAIDs for recovery of postoperative gut function in patients undergoing elective colorectal surgery.

METHOD

MEDLINE, EMBASE, CENTRAL and reference lists were searched with no date or language restrictions. Randomized controlled trials comparing the use of NSAIDs with placebo in the perioperative or postoperative period were identified. Included studies reported outcomes relevant to gut function: time to pass flatus or stool and time to tolerate an oral diet. The mean difference in time from surgery until passage of flatus, stool and tolerance of diet were meta-analysed using a random-effects model in RevMan 5.3.

RESULTS

This study identified 992 relevant articles. Five randomized controlled trials on patients undergoing elective colorectal surgery met our inclusion criteria and were meta-analysed. Compared with placebo, NSAIDs significantly improved the time to pass flatus (mean difference -9.44 h, 95% CI: -17.22, -1.65, I² = 70%, P = 0.02), time to pass stool (mean difference -12.09 h, 95% CI: -17.16, -7.02, I² = 0%, P < 0.001) and time to tolerate a diet (mean difference -11.95 h, 95% CI: -18.66, -5.24, I² = 0%, P < 0.001).

CONCLUSION

NSAIDs significantly improve time to gut recovery after elective colorectal surgery. Current evidence is not adequate to identify whether selective or nonselective drugs should be recommended. Further high-power studies using selective drugs are required.

Continuous administration of ramosetron with patient-controlled analgesia after laparoscopic distal gastrectomy does not delay postoperative bowel function recovery: A prospective, randomized, double-blinded study

BACKGROUND

Currently, 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists are indicated to slow gastrointestinal motility in the diarrhea-predominant subtype of irritable bowel syndrome. They are commonly used to prevent or treat postoperative nausea and vomiting (PONV) and opioid-induced nausea and vomiting (OINV). We conducted a prospective, randomized, double-blinded study to investigate whether the continuous administration of ramosetron, a selective 5-HT3 receptor antagonist, for preventing PONV and/or OINV after laparoscopic distal gastrectomy (LDG) might influence bowel function recovery.

METHODS

Patients scheduled to undergo LDG were randomly assigned to 1 of 3 treatment regimens: no prophylactic ramosetron (Group C); ramosetron 0.6 mg added to 2-day intravenous patient-controlled analgesia (IV-PCA) (Group R0.6); and ramosetron 1.2 mg added to 2-day IV-PCA (Group R1.2). Postoperative recovery profiles of bowel function, incidence of postoperative nausea/vomiting and pain, and perioperative data that affected bowel function recovery were evaluated.

RESULTS

Seventy-three patients completed the study protocol. Parameters associated with postoperative recovery of bowel function, such as time to first flatus, time to first bowel movement, time to first defecation, and time to commencement of soft diet, were not significantly different between the 3 groups. The incidence of nausea 2 to 24 hours after surgery was significantly lower in Group R0.6 (20.0%) and Group R1.2 (12.5%) than in Group C (45.8%) (P < .022). The ratio of complete response 2 to 24 hours after surgery was significantly higher in Group R0.6 (80.0%) and Group R1.2 (87.5%) than in Group C (54.2%) (P < .022). The incidence of retching 24 to 48 hours after surgery was significantly lower in Group R0.6 (0.0%) and Group R1.2 (4.2%) than in Group C (16.7%) (P < .043).

CONCLUSION

Continuous administration of ramosetron with patient-controlled analgesia to prevent PONV and OINV after LDG did not delay postoperative bowel function recovery.

Does an extreme age (≥80 years) affect outcomes in patients after liver cancer surgery? A meta-analysis

BACKGROUND

Increasing global life expectancy has resulted in a greater demand for cancer surgery in aged patients. However, whether extreme age causes poorer clinical outcomes remains unclear. This meta-analysis aimed to evaluate the impact of extreme age (≥80 years) on outcomes in patients after liver cancer surgery.

METHODS

A systematic search was performed to enrol relevant studies. Data were analysed using fixed-effects or random-effects models. Eight retrospective studies involving 253 participants older than 80 years were included.

RESULTS

Compared with younger patients, patients of extreme age (≥80 years) who had undergone curative liver cancer surgery experienced less operating time and blood loss (both P < 0.0001); a larger size (weighted mean difference = 0.48 cm, 95% confidence interval (CI) 0.08-0.87 cm; P = 0.02) and more advanced stage of hepatocellular carcinoma (risk ratio (RR) = 1.20, 95% CI 1.04-1.39; P = 0.01); a higher overall morbidity (RR = 1.24, 95% CI 1.05-1.47; P = 0.01); and more post-operative ileus (POI) (RR = 3.45, 95% CI 1.03-11.56; P = 0.04), delirium (RR = 3.04, 95% CI 1.36-6.78; P = 0.007) and cardiovascular events (RR = 6.17, 95% CI 2.79-13.60; P < 0.00001). No significant difference was noted in overall (hazard ratio (HR) = 1.15, 95% CI 0.87-1.53; P = 0.32) or disease-free (HR = 0.96, 95% CI 0.75-1.24; P = 0.77) survival.

CONCLUSION

Although an extreme age may not be a contraindication for undertaking liver cancer surgery, it may cause more morbidity. Perioperative intervention should be considered for prevention and early treatment of POI, delirium and cardiovascular events.

Evaluation of the Effect of Oral Pyridostigmine on the Ileus after Abdominal Surgery: A Blinded Randomized Clinical Trial

Postoperative ileus is one of the most important and common complications after abdominal surgery. This single-blind randomized clinical trial study was conducted with the aim of evaluating the effect of oral pyridostigmine (60 mg) on the duration and frequency of response to the treatment of ileus after abdominal surgery on 40 patients in two 20-subject groups of oral pyridostigmine (interventional) and starch (control) in 2015. All 40 people completed the study process and entered the final analysis. In the oral Pyridostigmin group (60 mg) the mean response time for the disposal of gas and stool were 5.4 ± 4.7 h and 4.9 ± 3.4 h, respectively. Most of the participants 10 (50%) (Disposal of stool) responded to treatment 4 h after the administration of oral pyridostigmine. In the starch group, the mean response time for the disposal of gas and stool were 32.4 ± 9.9 h and 36.2 ± 10.3 h, respectively. The mean treatment response time in two groups showed a significant difference between both groups (p = 0.001). Regarding the frequency of response to treatment (disposal of gas or stool) in the 24-h period after the initiation of treatment in the oral pyridostigmine group, 95% (n = 19) of the subjects responded to the treatment in the first 24 h. However, in the starch group, only 50% (n = 10) responded to treatment in the first 24 h, the results showed a significant difference between the two groups (p = 0.001). The results indicate that oral pyridostigmine can be used as a simple and effective treatment for gastrointestinal ileus.

Reduction in pain: Is it worth the gain? The effect of opioids on the GI tract

The use of opioid medications for acute and chronic pain has increased significantly in the past 20 years in the United States. Given the high density of opioid receptors in the gastrointestinal tract, side effects are common in these patients including constipation, dysphagia, bloating, nausea, and vomiting. These side effects, which are experienced by most patients who take opioids, can lead to significant impairment in quality of life. Unlike other side effects from opioids, gastrointestinal side effects do not diminish with continued use, often leading patients to reduce or discontinue their opioid treatment to relieve these side effects. Therefore, physicians must be aware and anticipate potential side effects in patients receiving opioids to ensure appropriate pain management.

Hyperactive cyclic motor activity in the distal colon after colonic surgery as defined by high-resolution colonic manometry

BACKGROUND

Recovery after colonic surgery is invariably delayed by disturbed gut motility. It is commonly assumed that colonic motility becomes quiescent after surgery, but this hypothesis has not been evaluated rigorously. This study quantified colonic motility through the early postoperative period using high-resolution colonic manometry.

METHODS

Fibre-optic colonic manometry was performed continuously before, during and after surgery in the left colon and rectum of patients undergoing right hemicolectomy, and in healthy controls. Motor events were characterized by pattern, frequency, direction, velocity, amplitude and distance propagated.

RESULTS

Eight patients undergoing hemicolectomy and nine healthy controls were included in the study. Colonic motility became markedly hyperactive in all operated patients, consistently dominated by cyclic motor patterns. Onset of cyclic motor patterns began to a minor extent before operation, occurring with increasing intensity nearer the time of surgery; the mean(s.d.) active duration was 12(7) per cent over 3 h before operation and 43(17) per cent within 1 h before surgery (P = 0.024); in fasted controls it was 2(4) per cent (P < 0·001). After surgery, cyclic motor patterns increased markedly in extent and intensity, becoming nearly continuous (active duration 94(13) per cent; P < 0·001), with peak frequency 2-4 cycles per min in the sigmoid colon. This postoperative cyclic pattern was substantially more prominent than in non-operative controls, including in the fed state (active duration 27(20) per cent; P < 0·001), and also showed higher antegrade velocity (P < 0·001).

CONCLUSION

Distal gut motility becomes markedly hyperactive with colonic surgery, dominated by cyclic motor patterns. This hyperactivity likely represents a novel pathophysiological aspect of the surgical stress response. Hyperactive motility may contribute to gut dysfunction after surgery, potentially offering a new therapeutic target to enhance recovery.

Intsy: a low-cost, open-source, wireless multi-channel bioamplifier system

OBJECTIVE

Multi-channel electrical recordings of physiologically generated signals are common to a wide range of biomedical fields. The aim of this work was to develop, validate, and demonstrate the practical utility of a high-quality, low-cost 32/64-channel bioamplifier system with real-time wireless data streaming capability.

APPROACH

The new 'Intsy' system integrates three main off-the-shelf hardware components: (1) Intan RHD2132 bioamplifier; (2) Teensy 3.2 microcontroller; and (3) RN-42 Bluetooth 2.1 module with a custom LabView interface for real-time data streaming and visualization. Practical utility was validated by measuring serosal gastric slow waves and surface EMG on the forearm with various contraction force levels. Quantitative comparisons were made to a gold-standard commercial system (Biosemi ActiveTwo).

MAIN RESULTS

Intsy signal quality was quantitatively comparable to that of the ActiveTwo. Recorded slow wave signals had high SNR (24  ±  2.7 dB) and wavefront propagation was accurately mapped. EMG spike bursts were characterized by high SNR (⩾10 dB) and activation timing was readily identified. Stable data streaming rates achieved were 3.5 kS s^-1 for wireless and 64 kS s^-1 for USB-wired transmission.

SIGNIFICANCE

Intsy has the highest channel count of any existing open-source, wireless-enabled module. The flexibility, portability and low cost ($1300 for the 32-channel version, or $2500 for 64 channels) of this new hardware module reduce the entry barrier for a range of electrophysiological experiments, as are typical in the gastrointestinal (EGG), cardiac (ECG), neural (EEG), and neuromuscular (EMG) domains.

The "rectosigmoid brake": Review of an emerging neuromodulation target for colorectal functional disorders

The regulation of gastrointestinal motility encompasses several overlapping mechanisms including highly regulated and coordinated neurohormonal circuits. Various feedback mechanisms or "brakes" have been proposed. While duodenal, jejunal, and ileal brakes are well described, a putative distal colonic brake is less well defined. Despite the high prevalence of colonic motility disorders, there is little knowledge of colonic motility owing to difficulties with organ access and technical difficulties in recording detailed motor patterns along its entire length. The motility of the colon is not under voluntary control. A wide range of motor patterns is seen, with long intervals of intestinal quiescence between them. In addition, the use of traditional manometric catheters to record contractile activity of the colon has been limited by the low number of widely spaced sensors, which has resulted in the misinterpretation of colonic motor patterns. The recent advent of high-resolution (HR) manometry is revolutionising the understanding of gastrointestinal motor patterns. It has now been observed that the most common motor patterns in the colon are repetitive two to six cycles per minute (cpm) propagating events in the distal colon. These motor patterns are prominent soon after a meal, originate most frequently in the rectosigmoid region, and travel in the retrograde direction. The distal prominence and the origin of these motor patterns raise the possibility of them serving as a braking mechanism, or the "rectosigmoid brake," to limit rectal filling. This review aims to describe what is known about the "rectosigmoid brake," including its physiological and clinical significance and potential therapeutic applications.

Gastrografin may reduce time to oral diet in prolonged post-operative ileus: a pooled analysis of two randomized trials

BACKGROUND

Gastrografin has been suggested as a rescue therapy for prolonged post-operative ileus (PPOI) but trial data has been inconclusive. This study aimed to determine the benefit of gastrografin use in patients with PPOI by pooling the results of two recent randomized controlled trials assessing the efficacy of gastrografin compared to placebo given at time of PPOI diagnosis.

METHODS

Anonymized, individual patient data from patients undergoing elective bowel resection for any indication were included, stoma closure was excluded. The primary outcome was duration of PPOI. Secondary outcomes were time to tolerate oral diet, passage of flatus/stool, requirement and duration of nasogastric tube, length of post-operative stay and rate of post-operative complications.

RESULTS

Individual patient data were pooled for analysis (53 gastrografin, 55 placebo). Gastrografin trended towards a reduction in PPOI duration compared to placebo, respectively, median 96 h (interquartile range, IQR, 78 h) versus median 120 h (IQR, 84 h), however, this result was non-significant (P = 0.11). In addition, no significant difference was detected between the two groups for time to passage of flatus/stool (P = 0.36) and overall length of stay (P = 0.35). Gastrografin conferred a significantly faster time to tolerate an oral diet compared to placebo (median 84 h versus median 107 h, P = 0.04). There was no difference in post-operative complications between the two interventions (P > 0.05).

CONCLUSION

Gastrografin did not significantly reduce PPOI duration or length of stay after abdominal surgery, but did reduce time to tolerate a solid diet. Further studies are required to clarify the role of gastrografin in PPOI.

A retrospective analysis on the relationship between intraoperative hypothermia and postoperative ileus after laparoscopic colorectal surgery

Postoperative ileus (POI) is an important factor prolonging the length of hospital stay following colorectal surgery. We retrospectively explored whether there is a clinically relevant association between intraoperative hypothermia and POI in patients who underwent laparoscopic colorectal surgery for malignancy within the setting of an enhanced recovery after surgery (ERAS) program between April 2016 and January 2017 at our institution. In total, 637 patients were analyzed, of whom 122 (19.2%) developed clinically and radiologically diagnosed POI. Overall, 530 (83.2%) patients experienced intraoperative hypothermia. Although the mean lowest core temperature was lower in patients with POI than those without POI (35.3 ± 0.5°C vs. 35.5 ± 0.5°C, P = 0.004), the independence of intraoperative hypothermia was not confirmed based on multivariate logistic regression analysis. In addition to three variables (high age-adjusted Charlson comorbidity index score, long duration of surgery, high maximum pain score during the first 3 days postoperatively), cumulative dose of rescue opioids used during the first 3 days postoperatively was identified as an independent risk factor of POI (odds ratio = 1.027 for each 1-morphine equivalent [mg] increase, 95% confidence interval = 1.014–1.040, P <0.001). Patients with hypothermia showed significant delays in both progression to a soft diet and discharge from hospital. In conclusion, intraoperative hypothermia was not independently associated with POI within an ERAS pathway, in which items other than thermal measures might offset its negative impact on POI. However, as it was associated with delayed discharge from the hospital, intraoperative maintenance of normothermia is still needed.

Effectiveness of Acupuncture for Early Recovery of Bowel Function in Cancer: A Systematic Review and Meta-Analysis

Objectives

The aim of this study was to evaluate the effects of acupuncture therapy to reduce the duration of postoperative ileus (POI) and to enhance bowel function in cancer patients.

Methods

A systematic search of electronic databases for studies published from inception until January 2017 was carried out from six databases. Randomized controlled trials (RCTs) involving the use of acupuncture and acupressure for POI and bowel function in cancer patients were identified. Outcomes were extracted from each study and pooled to determine the risk ratio and standardized mean difference.

Results

10 RCTs involving 776 cancer patients were included. Compared with control groups (no acupuncture, sham acupuncture, and other active therapies), acupuncture was associated with shorter time to first flatus and time to first defecation. A subgroup analysis revealed that manual acupuncture was more effective on the time to first flatus and the time to first defecation; electroacupuncture was better in reducing the length of hospital stay. Compared with control groups (sham or no acupressure), acupressure was associated with shorter time to first flatus. However, GRADE approach indicated a low quality of evidence.

Conclusions

Acupuncture and acupressure showed large effect size with significantly poor or inferior quality of included trials for enhancing bowel function in cancer patients after surgery. Further well-powered evidence is needed.

Gastrointestinal Motility Problems in Critically Ill Patients

Gastrointestinal (GI) motility problems are common complications in critical care patients. GI problems contribute to an increased risk of morbidity and mortality. Toxic megacolon (TM) is a type of acquired megacolon categorized as a medical emergency and includes severe inflammation affecting all layers of the colon wall. The high incidence of GI complications in critically ill patients requires the critical care nurse to provide close monitoring of patients at risk and an acute awareness of the causation, signs and symptoms, and treatment of various GI motility disorders, including gastroparesis, ileus, and TM.

Acute colonic pseudo-obstruction: A systematic review of aetiology and mechanisms

AIM

To critically review the literature addressing the definition, epidemiology, aetiology and pathophysiology of acute colonic pseudo-obstruction (ACPO).

METHODS

A systematic search was performed to identify articles investigating the aetiology and pathophysiology of ACPO. A narrative synthesis of the evidence was undertaken.

RESULTS

No consistent approach to the definition or reporting of ACPO has been developed, which has led to overlapping investigation with other conditions. A vast array of risk factors has been identified, supporting a multifactorial aetiology. The pathophysiological mechanisms remain unclear, but are likely related to altered autonomic regulation of colonic motility, in the setting of other predisposing factors.

CONCLUSION

Future research should aim to establish a clear and consistent definition of ACPO, and elucidate the pathophysiological mechanisms leading to altered colonic function. An improved understanding of the aetiology of ACPO may facilitate the development of targeted strategies for its prevention and treatment.

Acupuncture for enhancing early recovery of bowel function in cancer: Protocol for a systematic review

BACKGROUND

Cancer patients undergoing surgical procedure often suffer from bowel dysfunction and postoperative ileus (POI). Cancer management for early recovery of bowel function is still a challenging topic. Acupuncture has been commonly used in a variety of gastrointestinal diseases. The aim of this study is to evaluate the effects of acupuncture therapy to reduce the duration of POI and enhance bowel function in cancer patients.

METHODS

We will systematically screen all randomized controlled trials (RCTs) published through electronically and hand searching. The following search engines including Medline, EMBASE, Cochrane CENTRAL, the Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, the Chinese Biomedical Literature Database, the China National Knowledge Infrastructure, VIP Information, Wanfang Data, one Japanese database (Japan Science and Technology Information Aggregator, Electronic) and 2 Korean Medical Databases (Korean Studies Information, and Data Base Periodical Information Academic) will be retrieved. Supplementary sources will be searched including gray literature, conference proceedings, and potential identified publications. Two reviewers will independently conduct the trial inclusion, data extraction and assess the quality of studies. The time to first passing flatus and time to first bowel motion will be assessed as the primary outcomes. Adverse effects, time to first bowel sound, visual analog scale (VAS) pain score, hospital stay, and postoperative analgesic requirement will be measured as secondary outcomes. Methodological quality will be evaluated according to the Cochrane risk of bias. Details of interventions will be assessed by the Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA) checklist. All analyses will be applied by RevMan (version 5.3) and StataSE (version 12).

ETHICS AND DISSEMINATION

This systematic review will provide up-to-date information on acupuncture therapy for early recovery of bowel function in cancer patients. This review does not require ethical approval and will be reported in a peer-reviewed journal and presented at a relevant conference.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42016049633.

Effects of coffee consumption on gut recovery after surgery of gynecological cancer patients: a randomized controlled trial

BACKGROUND

Paralytic ileus that develops after elective surgery is a common and uncomfortable complication and is considered inevitable after an intraperitoneal operation.

OBJECTIVE

The purpose of this study was to investigate whether coffee consumption accelerates the recovery of bowel function after complete staging surgery of gynecologic cancers.

STUDY DESIGN

In this randomized controlled trial, 114 patients were allocated preoperatively to either postoperative coffee consumption with 3 times daily (n=58) or routine postoperative care without coffee consumption (n=56). Total abdominal hysterectomy and bilateral salpingo-oophorectomy with systematic pelvic and paraaortic lymphadenectomy were performed on all patients as part of complete staging surgery for endometrial, ovarian, cervical, or tubal cancer. The primary outcome measure was the time to the first passage of flatus after surgery. Secondary outcomes were the time to first defecation, time to first bowel movement, and time to tolerance of a solid diet.

RESULTS

The mean time to flatus (30.2±8.0 vs 40.2±12.1 hours; P<.001), mean time to defecation (43.1±9.4 vs 58.5±17.0 hours; P<.001), and mean time to the ability to tolerate food (3.4±1.2 vs 4.7±1.6 days; P<.001) were reduced significantly in patients who consumed coffee compared with control subjects. Mild ileus symptoms were observed in 17 patients (30.4%) in the control group compared with 6 patients (10.3%) in the coffee group (P=.01). Coffee consumption was well-tolerated and well-accepted by patients, and no intervention-related side-effects were observed.

CONCLUSION

Coffee consumption after total abdominal hysterectomy and systematic paraaortic lymphadenectomy expedites the time to bowel motility and the ability to tolerate food. This simple, cheap, and well-tolerated treatment should be added as an adjunct to the postoperative care of gynecologic oncology patients.

Increased incidence of prolonged ileus after colectomy for inflammatory bowel diseases under ERAS protocol: a cohort analysis

BACKGROUND

Postoperative ileus is a common problem after colorectal surgery. The aim of the study was to investigate the incidence and risk factors for prolonged postoperative ileus (POI) after colectomy for inflammatory bowel diseases (IBDs).

METHODS

Consecutive patients who underwent colorectal resection for IBD versus colorectal cancer (CRC) patients under enhanced recovery after surgery protocol were retrospectively analyzed. Primary assessment end point is the incidence of prolonged POI (>4 days); secondary end points were GI-2 recovery (time to first toleration of solid food and first bowel movement), nasogastric tube reinsertion, and postoperative length of stay. Risk factors for prolonged POI in IBD patients were assessed by multiple logistic regression analysis with P score matching.

RESULTS

The incidence of prolonged POI was higher in IBD versus CRC group (28.8% versus 14.8%, P < 0.001). Patients with IBD had a longer time to GI-2 recovery (4.8 ± 2.1 versus 3.7 ± 1.4 d, P < 0.001), postoperative length of stay (10.7 ± 6.2 versus 7.9 ± 5.3 d, P < 0.001), higher incidence of nasogastric tube reinsertion (9.8% versus 4.0%, P = 0.02). After propensity-score matching analysis, the differences were still significant. Preoperative steroid use >20 mg/d (odds ratio, [OR] = 2.19, P = 0.048), hypoalbuminemia (<35 g/L; OR 2.72, P = 0.03), systemic inflammatory response syndrome status (OR 4.91, P = 0.03), and postoperative intraabdominal sepsis (OR 9.31, P = 0.001) were independent risk factors for prolonged POI in IBD patients.

CONCLUSIONS

In the setting of enhanced recovery after surgery, colectomy for IBD is associated with delayed gastrointestinal function recovery and higher incidence of prolonged POI compared to CRC patients. Normalizing preoperative albumin level, weaning off steroids, reducing preoperative systemic inflammatory response syndrome, and early management of postoperative intraabdominal sepsis may reduce POI in IBD population.

Prospective comparison of return of bowel function after left versus right colectomy

BACKGROUND

Passage of flatus and stool represents a key milestone in recovery after colonic resections. Colorectal surgeons may hold varied expectations regarding recovery rates after left- versus right-sided colectomies, but there is currently little evidence to inform post-operative care. This study prospectively compared gut function recovery after left- versus right-sided resections.

METHODS

Prospective data were analysed from 94 consecutive patients undergoing elective colorectal resections with primary anastomosis at Auckland City Hospital. Patients having ileostomies were excluded. Primary analysis compared time to first bowel motion between left- versus right-sided resections, excluding patients who developed prolonged post-operative ileus, while secondary analyses compared length of stay, rates of prolonged ileus and other complications.

RESULTS

Analysis included 42 patients with left-sided and 52 with right-sided resections. No significant differences were observed for complications (P = 0.1), length of stay (P = 0.9) or development of prolonged ileus (P = 0.2). Rate of return of bowel function was faster in patients after left-sided resections (median 2.5 versus 4 days; P = 0.03 by Log-rank (Mantel-Cox) test), when patients with prolonged post-operative ileus were excluded. An association was also identified between length of bowel resected and time to recovery of bowel function for right-sided (P = 0.02) but not left-sided resections (P = 0.9).

CONCLUSION

This study shows that for patients who do not progress to prolonged ileus, those with left-sided resections experience faster return of bowel function when compared with those having right-sided resections. The reason for this finding is currently unknown and deserves further attention.

Postoperative ileus: in search of an international consensus on definition, diagnosis, and treatment

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.

Impact of elemental diet on early recovery after laparoscopic colectomy: findings of a randomized controlled trial

PURPOSE

An amino acid-containing elemental diet (ED) does not require digestion for nutritional absorption, making it a good option for patients with gastrointestinal malabsorption. We conducted a randomized trial to confirm that perioperative ED enhanced the recovery of patients undergoing laparoscopic colectomy.

METHODS

Patients in the intervention arm received commercially available ED from the day prior to surgery until postoperative day (POD) 3, whereas patients in the control group received a conventional perioperative diet program. To verify the endpoints, "estimated minimum length of stay in hospital after surgery" (emLOS) was defined as the number of days necessary to reach all the five criteria; namely, "sufficient oral intake", "sufficient pain control", "withdrawal of intravenous alimentation", "no abnormal findings in routine examinations", and "no rise in fever".

RESULTS

A total of 102 patients were randomized, 94 of whom were analyzed (ED 45, control 49). There was no morbidity or mortality. Shorter emLOS (POD 4 vs. POD 7; p = 0.018), earlier resumption of sufficient oral intake (POD 3 vs. POD 4; p = 0.034) and faster recovery to defecation (2.2 vs. 3.1 days; p = 0.005) were observed in the ED group vs. the control group.

CONCLUSIONS

The perioperative ingestion of ED by patients undergoing laparoscopic colectomy is safe and can reduce the postoperative hospital stay by supporting the acceleration of oral intake.

[Treatment of postoperative impairment of gastrointestinal motility, cholangitis and pancreatitis]

Although the mortality associated with major hepatopancreaticobiliary surgery has continuously decreased during the last decades, the morbidity of these procedures remains high. Functional disturbances of normal gastrointestinal motility as well as inflammation and infections of surgically treated organs are frequent complications resulting in considerably prolonged lengths of stay in hospital and increased healthcare costs. This review article highlights the therapeutic approaches and recent developments in the treatment of delayed gastric emptying, prolonged postoperative ileus, postoperative cholangitis and pancreatitis after hepatopancreaticobiliary surgery. Current practice is discussed on the basis of recent results in basic and clinical research, review articles, meta-analyses and guidelines.

Restoration of normal colonic motor patterns and meal responses after distal colorectal resection

Background

Colorectal resections alter colonic motility, including disruption of control by neural or bioelectrical cell networks. The long-term impact of surgical resections and anastomoses on colonic motor patterns has, however, never been assessed accurately. Fibreoptic high-resolution colonic manometry was employed to define motility in patients who had undergone distal colorectal resection.

Methods

Recruited patients had undergone distal colorectal resections more than 12 months previously, and had normal bowel function. Manometry was performed in the distal colon (36 sensors; 1-cm intervals), with 2-h recordings taken before and after a meal, with comparison to controls. Analysis quantified all propagating events and frequencies (cyclical, short single, and long single motor patterns), including across anastomoses.

Results

Fifteen patients and 12 controls were recruited into the study. Coordinated propagating events directly traversed the healed anastomoses in nine of 12 patients with available data, including antegrade and retrograde cyclical, short single and long single patterns. Dominant frequencies in the distal colon were similar in patients and controls (2–3 cycles/min) (antegrade P = 0·482; retrograde P = 0·178). Compared with values before the meal, the mean(s.d.) number of dominant cyclical retrograde motor patterns increased in patients after the meal (2·1(2·7) versus 32·6(31·8) in 2 h respectively; P &lt; 0·001), similar to controls (P = 0·178), although the extent of propagation was 41 per cent shorter in patients, by a mean of 3·4 cm (P = 0·003). Short and long single propagating motor patterns were comparable between groups in terms of frequency, velocity, extent and amplitude.

Conclusion

Motility patterns and meal responses are restored after distal colorectal resection in patients with normal bowel function. Coordinated propagation across healed anastomoses may indicate regeneration of underlying cellular networks.

Incidence of prolonged postoperative ileus after colorectal surgery: a systematic review and meta-analysis

AIM

Prolonged postoperative ileus (PPOI) after colorectal surgery remains a leading cause of delayed postoperative recovery and prolonged hospital stay. Its exact incidence is unknown. The aim of this systematic review is to investigate the definitions and incidence of PPOI previously described.

METHOD

MEDLINE, Embase and the Cochrane Database of Systematic Reviews (up to July 2014) were searched. Two authors independently reviewed citations using predefined inclusion and exclusion criteria.

RESULTS

The search strategy yielded 3233 citations; 54 were eligible, comprising 18 983 patients. Twenty-six studies were prospective [17 of these being randomized controlled trials (RCTs)] and 28 were retrospective. Meta-analysis revealed an incidence of PPOI of 10.3% (95% CI 8.4-12.5) and 10.2% (95% CI 5.6-17.8) for non-RCTs and RCTs, respectively. Significant heterogeneity was observed for both non-RCTs and for RCTs. The used definition of PPOI, the type of surgery and access (laparoscopic, open) and the duration of surgery lead to significant variability of reported PPOI incidence between studies. The incidence of PPOI is lower after laparoscopic colonic resection.

CONCLUSION

There is a large variation in the reported incidence of PPOI. A uniform definition of PPOI is needed to allow meaningful inter-study comparisons and to evaluate strategies to prevent PPOI.

Patterns of Brain Activation and Meal Reduction Induced by Abdominal Surgery in Mice and Modulation by Rikkunshito

Abdominal surgery inhibits food intake and induces c-Fos expression in the hypothalamic and medullary nuclei in rats. Rikkunshito (RKT), a Kampo medicine improves anorexia. We assessed the alterations in meal microstructure and c-Fos expression in brain nuclei induced by abdominal surgery and the modulation by RKT in mice. RKT or vehicle was gavaged daily for 1 week. On day 8 mice had no access to food for 6–7 h and were treated twice with RKT or vehicle. Abdominal surgery (laparotomy-cecum palpation) was performed 1–2 h before the dark phase. The food intake and meal structures were monitored using an automated monitoring system for mice. Brain sections were processed for c-Fos immunoreactivity (ir) 2-h after abdominal surgery. Abdominal surgery significantly reduced bouts, meal frequency, size and duration, and time spent on meals, and increased inter-meal interval and satiety ratio resulting in 92–86% suppression of food intake at 2–24 h post-surgery compared with control group (no surgery). RKT significantly increased bouts, meal duration and the cumulative 12-h food intake by 11%. Abdominal surgery increased c-Fos in the prelimbic, cingulate and insular cortexes, and autonomic nuclei, such as the bed nucleus of the stria terminalis, central amygdala, hypothalamic supraoptic (SON), paraventricular and arcuate nuclei, Edinger-Westphal nucleus (E-W), lateral periaqueduct gray (PAG), lateral parabrachial nucleus, locus coeruleus, ventrolateral medulla and nucleus tractus solitarius (NTS). RKT induced a small increase in c-Fos-ir neurons in the SON and E-W of control mice, and in mice with surgery there was an increase in the lateral PAG and a decrease in the NTS. These findings indicate that abdominal surgery inhibits food intake by increasing both satiation (meal duration) and satiety (meal interval) and activates brain circuits involved in pain, feeding behavior and stress that may underlie the alterations of meal pattern and food intake inhibition. RKT improves food consumption post-surgically that may involve modulation of pain pathway.

Risk Factors for Intestinal Obstruction After Ladd Procedure

Intestinal obstruction is a common complication after Ladd procedure. Ninety-three cases who had undergone the Ladd procedure between 1977 and 2013 treated at our own institution were retrospectively reviewed to identify the causes and risk factors for intestinal obstruction. The Ladd procedure has been performed without any intestinal fixing. Of the 87 cases who survived to discharge, intestinal obstruction was observed in 22 (25.3%). Among the cases with intestinal obstruction, 13 (59.1%) showed intestinal ischemia at the initial operation; this incidence was notably high, although it is low when only those cases with another concurrent surgical digestive disease are considered. All cases of intestinal obstruction were caused not by recurrent volvulus, but by adhesion between the intestine and the mesentery. Intestinal fixing is not required to prevent recurrent volvulus, but it is important to achieve adequate widening of the mesenteric base. The risk of intestinal obstruction after the Ladd procedure, on the other hand, is high. Moreover, patients with intestinal ischemia have an increased risk of intestinal obstruction.

Development of a risk stratification system for the occurrence of prolonged postoperative ileus after colorectal surgery: a prospective risk factor analysis

BACKGROUND

Management strategies for prolonged postoperative ileus (PPOI) are principally conservative and it is therefore valuable to shift attention to prevention. This study aimed to identify prospectively the perioperative risk factors for the development of PPOI and create a tool to predict its occurrence.

METHODS

Patients undergoing elective colorectal surgery at Auckland District Health Board between September 2012 and June 2014 were enrolled. In total, 92 variables were investigated prospectively with uniform application of a standardized definition of PPOI. Logistic regression and area under receiver operating characteristic curves (AUC) were used to generate risk stratification models.

RESULTS

PPOI occurred in 88 of 327 patients (26.9%). Independent predictors of PPOI were male gender (odds ratio [OR], 3.01), decreasing preoperative albumin (OR, 1.11 per g/L unit), open or converted technique (OR, 6.37 [vs laparoscopic]), increasing wound size (OR, 1.09 [per cm]), operative difficulty (OR, 1.28 [per unit on 10-point Likert scale]), operative bowel handling (OR, 1.38 [per unit on 10-point Likert scale]), red cell transfusion (OR, 1.84 [per unit]), intravenous crystalloid administration (OR, 1.55 [per liter]), and delayed first mobilization (OR, 1.39 [per day]). The I-Score assimilated preoperative and intraoperative variables to generate a score out of 6 with a 7-fold increase in risk from low-risk to high-risk strata and fair predictive capacity (AUC, 0.742; 95% CI, 0.684-0.799).

CONCLUSION

Independent predictors for the development of PPOI have been identified prospectively and used to construct a novel risk stratification model.

Mangiferin ameliorates the intestinal inflammatory response and the impaired gastrointestinal motility in mouse model of postoperative ileus

Our previous study has shown that mangiferin (MGF), a glucosylxanthone from Mangifera indica, exerts gastrointestinal prokinetic action involving a cholinergic mechanism. Postoperative ileus (POI) is a temporary disturbance in gastrointestinal motility following surgery, and intestinal inflammatory response plays a critical role in the pathogenesis of POI. The present study investigated to know whether MGF having anti-inflammatory and prokinetic actions can ameliorate the intestinal inflammation and impaired gastrointestinal transit seen in the mouse model of POI. Experimental POI was induced in adult male Swiss mice by standardized small intestinal manipulation (IM). Twenty-four hours later, gastrointestinal transit was assessed by charcoal transport. MGF was administered orally 1 h before the measurement of GIT. To evaluate the inflammatory response, plasma levels of proinflammatory cytokines TNF-α, IL-1β, IL-6, and chemokine MCP-1, and the myeloperoxidase activity, nitrate/nitrite level, and histological changes of ileum were determined in mice treated or not with MGF. Experimental POI in mice was characterized by decreased gastrointestinal transit and marked intestinal and systemic inflammatory response. MGF treatment led to recovery of the delayed intestinal transit induced by IM. MGF in ileum significantly inhibited the myeloperoxidase activity, a marker of neutrophil infiltration, and nitrate/nitrite level and reduced the plasma levels of TNF-α, IL-1β, IL-6, and MCP-1 as well. MGF treatment ameliorates the intestinal inflammatory response and the impaired gastrointestinal motility in the mouse model of POI.

Postoperative ileus: Recent developments in pathophysiology and management

BACKGROUND & AIMS

Postoperative ileus (POI) is a frequent occurrence after abdominal and other types of surgery, and is associated with significant morbidity and costs to health care providers. The aims of this narrative review were to provide an update of classification systems, preventive techniques, pathophysiological mechanisms, and treatment options for established POI.

METHODS

The Web of Science, MEDLINE, PubMed and Google Scholar databases were searched using the key phrases 'ileus', 'postoperative ileus' and 'definition', for relevant studies published in English from January 1997 to August 2014.

RESULTS

POI is still a problematic and frequent complication of surgery. Fluid overload, exogenous opioids, neurohormonal dysfunction, and gastrointestinal stretch and inflammation are key mechanisms in the pathophysiology of POI. Evidence is supportive of thoracic epidural analgesia, avoidance of salt and water overload, alvimopan and gum chewing as measures for the prevention of POI, and should be incorporated into perioperative care protocols. Minimal access surgery and avoidance of nasogastric tubes may also help. Novel strategies are emerging, but further studies are required for the treatment of prolonged POI, where evidence is still lacking.

CONCLUSIONS

Although POI is often inevitable, methods to reduce its duration and facilitate recovery of postoperative gastrointestinal function are evolving rapidly. Utilisation of standardised diagnostic classification systems will help improve applicability of future studies.