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Silva SM, Jerônimo MS, Silva-Pereira I, Bocca AL, Sousa JB. Effects of bromopride on expression of metalloproteinases and interleukins in left colonic anastomoses: an experimental study. Braz J Med Biol Res 2014; 47:911-6. [PMID: 25140813 PMCID: PMC4181227 DOI: 10.1590/1414-431x20143431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 06/02/2014] [Indexed: 11/22/2022] Open
Abstract
Anastomotic dehiscence is the most severe complication of colorectal surgery.
Metalloproteinases (MMPs) and interleukins (ILs) can be used to analyze the healing
process of anastomosis. To evaluate the effects of bromopride on MMP and cytokine
gene expression in left colonic anastomoses in rats with or without induced abdominal
sepsis, 80 rats were divided into two groups for euthanasia on the third or seventh
postoperative day (POD). They were then divided into subgroups of 20 rats for sepsis
induction or not, and then into subgroups of 10 rats for administration of bromopride
or saline. Left colonic anastomosis was performed and abdominal sepsis was induced by
cecal ligation and puncture. A colonic segment containing the anastomosis was removed
for analysis of gene expression of MMP-1α, MMP-8, MMP-13, IL-β, IL-6, IL-10, tumor
necrosis factor-α (TNF-α), and interferon-γ (IFN-γ). On the third POD, bromopride was
associated with increased MMP-1α, MMP-13, IL-6, IFN-γ, and IL-10 gene expression. On
the seventh POD, all MMP transcripts became negatively modulated and all IL
transcripts became positively modulated. In the presence of sepsis, bromopride
administration increased MMP-8 and IFN-γ gene expression and decreased MMP-1, TNF-α,
IL-6, and IL-10 gene expression on the third POD. On the seventh POD, we observed
increased expression of MMP-13 and all cytokines, except for TNF-α. In conclusion,
bromopride interferes with MMP and IL gene expression during anastomotic healing.
Further studies are needed to correlate these changes with the healing process.
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Affiliation(s)
- S M Silva
- Programa de Pós-Graduação em Ciências Médicas, Faculdade de Medicina, Universidade de Brasília, Brasília, DF, Brasil
| | - M S Jerônimo
- Programa de Pós-Graduação em Patologia Molecular, Faculdade de Medicina, Universidade de Brasília, Brasília, DF, Brasil
| | - I Silva-Pereira
- Departamento de Biologia Celular, Instituto de Biologia, Universidade de Brasília, Brasília, DF, Brasil
| | - A L Bocca
- Departamento de Biologia Celular, Instituto de Biologia, Universidade de Brasília, Brasília, DF, Brasil
| | - J B Sousa
- Departamento de Clínica Cirúrgica, Faculdade de Medicina, Universidade de Brasília, Brasília, DF, Brasil
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Morais PHAD, Silva NGD, Oliveira MVMD, Brandão AM, Silva SME, Carneiro FP, Sousa JBD. Effects of prokinetic drugs on the abdominal wall wound healing of rats submitted to segmental colectomy and colonic anastomosis. Acta Cir Bras 2012; 27:448-53. [PMID: 22760828 DOI: 10.1590/s0102-86502012000700003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 05/18/2012] [Indexed: 11/22/2022] Open
Abstract
PURPOSE To assess the effect of prokinetic agents on abdominal wall wound healing in rats submitted to segmental colectomy and colonic anastomosis. METHODS Sixty rats were randomly allocated into three groups according to the agents they would receive in the postoperative period: M (metoclopramide); B (bromopride); and C (control, saline 0.9%). Surgical procedures were performed identically in all animals, and consisted of a midline laparotomy followed by resection of a 1-cm segment of large bowel with end-to-end anastomosis. The abdominal wall was closed in two layers with running stitches. Abdominal wall samples were collected on the 3rd or 7th postoperative day for measurement of breaking (tensile) strength and histopathological assessment. RESULTS There were no statistically significant differences in tensile strength of the abdominal wall scar between groups M, B, and C, nor between the three and seven days after surgery subgroups. On histopathological assessment, there were no statistically significant between-group differences in collagen deposition or number of fibroblasts at the wound site CONCLUSION Use of the prokinetic drugs metoclopramide or bromopride had no effect on abdominal wall healing in rats submitted to segmental colectomy and colonic anastomosis.
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Abstract
Postoperative ileus after gastrointestinal surgery results from many factors, including the effects of surgical trauma, anesthetic agents, hyperactivity of the sympathetic nervous system, local inflammatory reactions, and the use of opioids in the postoperative period. Postoperative ileus can lead to potential complications and may prolong patients' hospitalization, thereby leading to an increase in healthcare costs. There have been recent efforts to improve the understanding of the pathogenesis of postoperative ileus and to develop new treatments to prevent or minimize its occurrence. Here, we present a review of the factors related to the development of postoperative ileus and new therapies directed at its prevention.
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Balsama L, Weese J. Alvimopan: a peripheral acting µ-opioid-receptor antagonist used for the treatment of postoperative ileus. ACTA ACUST UNITED AC 2007. [DOI: 10.2217/14750708.4.5.653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Kennedy JM, van Rij AM. Drug absorption from the small intestine in immediate postoperative patients. Br J Anaesth 2006; 97:171-80. [PMID: 16731573 DOI: 10.1093/bja/ael117] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The effects of surgery on gastric emptying have been documented for a considerable time, but less is known about the effects in the small intestine. It is thought that there is minimal diminution in the absorptive capacity of the small intestine after operation, although there is no literature on drug absorption in the early period after surgery. This study investigated drug absorption from the small bowel in patients undergoing abdominal surgery. METHODS A prospective study of patients undergoing major abdominal surgery in which patients acted as their own preoperative controls was carried out. Patients were administered the test substances, acetaminophen and (99m)TcDTPA, before operation and 2 days after operation. Small intestine transit times, plasma concentrations and other pharmacokinetic variables were compared using Student's paired t-test. Two complementary studies were carried out to establish pharmacokinetic parameters. RESULTS There were no significant differences in the pre- and postoperative values of t(max), area under the curve, and area under the moment curve (AUMC) before and after operation (P>0.05). There were significant differences between the pre- and postoperative values of C(max) [C(max (preop))>C(max (postop)); P<0.05] and the pre- and postoperative values of mean residence time (MRT) [MRT((preop))<MRT((postop)); P<0.01]. CONCLUSIONS Drug absorption from the small bowel in the postoperative patient does not differ significantly from its preoperative absorptive capacity.
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Affiliation(s)
- J M Kennedy
- School of Pharmacy, University of Otago, Dunedin, New Zealand.
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Quah HM, Samad A, Neathey AJ, Hay DJ, Maw A. Does gum chewing reduce postoperative ileus following open colectomy for left-sided colon and rectal cancer? A prospective randomized controlled trial. Colorectal Dis 2006; 8:64-70. [PMID: 16519641 DOI: 10.1111/j.1463-1318.2005.00884.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Postoperative ileus is common after colorectal resection and can prolong hospital stay. Gum chewing, a type of sham feeding, may to stimulate gut motility via cephalic-vagal stimulation, and thereby reduce the length of ileus. This study aimed to determine whether gum chewing in the immediate postoperative period facilitated recovery from ileus following resection for left-sided colorectal cancer. METHODS In a prospective randomized control trial, 38 patients undergoing open surgery for left-sided colorectal cancer were allocated to standard postoperative care (control group, n = 19) or to standard postoperative care plus the immediate use of chewing gum (treatment group, n = 19). RESULT Control patients passed flatus by mean of 2.7 days (SD 1.0) and faeces by 3.9 days (SD 1.5); for the treatment group, this was 2.4 days (SD 1.0) and 3.2 days (SD 1.5) respectively, (NS, P = 0.56 and P = 0.38). Length of hospital stay was 11.1 days (SD 7.3) in control group and 9.4 days (SD 2.5) in the treatment group (NS, P = 0.75). CONCLUSION The addition of gum chewing to a standardized postoperative regimen did not reduce the period of postoperative ileus or shorten length of stay following open surgery for left-sided colorectal cancer.
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Affiliation(s)
- H M Quah
- Department of Colorectal and General Surgery, Glan Clwyd Hospital, Rhyl, UK
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Abstract
PURPOSE Postoperatively, some patients experience a prolonged inhibition of coordinated bowel activity, which causes accumulation of secretions and gas, resulting in nausea, vomiting, abdominal distension, and pain. This prolonged inhibition can take days or weeks to resolve and often is referred to as postoperative paralytic ileus lasting more than three days after surgery. This article reviews the etiology, pathophysiology, and treatment options of postoperative ileus. METHODS The relevant literature from 1965 to 2003 was identified and reviewed using MEDLINE database of the U.S. Medical Library of Medicine. Both retrospective and prospective studies were included in this review. RESULTS The pathophysiology of postoperative ileus is multifactorial. The duration of postoperative ileus correlates with the degree of surgical trauma and is most extensive after colonic surgery. However, postoperative ileus can develop after all types of surgery including extraperitoneal surgery. A variety of treatment options have been used to decrease the duration of postoperative ileus. However, it is difficult to compare these studies because of small sample sizes and differences in operations performed, anesthesia protocols provided both intraoperatively and postoperatively, patient comorbidities, and in the measured end points, such as the time to the presence of bowel sounds, flatus, or bowel movements, tolerance of solid food, or discharge from the hospital. However, despite these drawbacks, some conclusions can be made. CONCLUSIONS Paralytic postoperative ileus continues to be a significant problem after abdominal and other types of surgery. The etiology is multifactorial and is best treated with a combination of different approaches. Currently, the important factors that could effect the duration and recovery from postoperative ileus include limitation of narcotic use by substituting alternative medications such as nonsteroidals and placing a thoracic epidural with local anesthetic when possible. The selective use of nasogastric decompression and correction of electrolyte imbalances also are important factors to consider.
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Affiliation(s)
- Mirza K Baig
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, Florida 33331, USA
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Abstract
The pathogenesis of postoperative ileus (PI) is multifactorial, and includes activation of inhibitory reflexes, inflammatory mediators and opioids (endogenous and exogenous). Accordingly, various strategies have been employed to prevent PI. As single-modality treatment, continuous postoperative epidural analgesia including local anaesthetics has been most effective in the prevention of PI. Choice of anaesthetic technique has no major impact on PI. Minimally invasive surgery reduces PI, in accordance with the sustained reduction in the inflammatory responses, while the effects of early institution of oral nutrition on PI per se are minor. Several pharmacological agents have been employed to resolve PI (propranolol, dihydroergotamine, neostigmine, erythromycin, cisapride, metoclopramide, cholecystokinin, ceruletide and vasopressin), most with either limited effect or limited applicability because of adverse effects. The development of new peripheral selective opioid antagonists is promising and has been demonstrated to shorten PI significantly. A multi-modal rehabilitation programme including continuous epidural analgesia with local anaesthetics, enforced nutrition and mobilisation may reduce PI to 1-2 days after colonic surgery.
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Affiliation(s)
- Kathrine Holte
- Department of Surgical Gastroenterology, Hvidovre University Hospital, Hvidovre, Denmark.
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Abstract
This article will review the pathophysiology of postoperative ileus, with emphasis on potential therapeutic targets, and examine the efficacy of pharmacologic and nonpharmacologic interventions. Proposed mechanisms include actuation of spinal and local sympathetic neural reflexes, inflammatory mediation, and exacerbation by anesthetic or surgical procedures. Some procedures or agents have shown clinical benefit, and these include use of laparoscopic surgery, thoracic epidurals, nonsteroidal anti-inflammatory drugs, and opiate antagonists. Other procedures may be helpful with low risk of adverse effects. These include early feeding and ambulation, laxatives, and possibly neostigmine.
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Affiliation(s)
- Brian Behm
- Division of Gastroenterology, University of California San Francisco, San Francisco, California, USA
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Itoh T, Yamakawa J, Mai M, Yamaguchi N, Kanda T. The effect of the herbal medicine dai-kenchu-to on post-operative ileus. J Int Med Res 2002; 30:428-32. [PMID: 12235926 DOI: 10.1177/147323000203000410] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Post-operative ileus (PI) is an inevitable adverse consequence of abdominal surgical procedures. We performed a randomized study of the effects of the herbal medicine dai-kenchu-to (DKT) on 24 patients with PI. Patients received either 15 g of oral DKT or placebo daily for 14 days. The effects on upper gastrointestinal motility, frequency of secondary operation and recurrence of PI were investigated. The frequency of surgical operation was significantly lower in patients receiving DKT compared with placebo. Oral administration of DKT was clinically effective for PI in reducing both the need for further surgery and the recurrence of PI.
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Affiliation(s)
- T Itoh
- Department of General Medicine, Kanazawa Medical University, Ishikawa, Japan
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Affiliation(s)
- Timothy G Schuster
- Department of Urology, University of Michigan School of Medicine, Ann Arbor, Michigan 48109-0330, USA
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Abstract
Postoperative ileus (POI) is an inevitable adverse consequence of surgical procedures. In fact, prolonged POI can lead to patient discomfort, decreased mobility, delayed enteral feeding, and ultimately, prolonged hospitalizations and increased costs. It is believed that POI occurs as a result of inhibitory neural reflexes and inflammatory processes. The use of postoperative opioids also appears to contribute to ileus. Recently, the potential influence of endogenous opioids, in addition to exogenous opioids, on the pathogenesis of ileus has come to light and spurred investigations into new treatment strategies. Over the years, several treatment modalities have become accepted management options for POI; chief among these are nasogastric suction and prokinetic agents. However, data demonstrating that these agents reduce the duration of POI are limited. Of current treatment modalities, use of epidural local anesthetics appears to be the most effective means of reducing POI. Other potentially effective treatments include early enteral feeding and less invasive surgical procedures. Together, these techniques have reduced the length of stay after colonic surgery to 2 to 3 days. Future studies, including those incorporating investigational agents, such as kappa-opioid agonists and peripheral mu-opioid antagonists, into a multimodal regimen, may offer new treatment options to further impact POI duration.
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Affiliation(s)
- H Kehlet
- Hvidovre University Hospital, Department of Surgical Gastroenterology, DK-2650, Copenhagen, Denmark.
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Abstract
BACKGROUND Postoperative ileus has traditionally been accepted as a normal response to tissue injury. No data support any beneficial effect of ileus and indeed it may contribute to delayed recovery and prolonged hospital stay. Efforts should, therefore, be made to reduce such ileus. METHODS Material was identified from a Medline search of the literature, previous review articles and references cited in original papers. This paper updates knowledge on the pathophysiology and treatment of postoperative ileus. RESULTS AND CONCLUSION Pathogenesis mainly involves inhibitory neural reflexes and inflammatory mediators released from the site of injury. The most effective method of reducing ileus is thoracic epidural blockade with local anaesthetic. Opioid-sparing analgesic techniques and non-steroidal anti-inflammatory agents also reduce ileus, as does laparoscopic surgery. Of the prokinetic agents only cisapride is proven beneficial; the effect of early enteral feeding remains unclear. However, postoperative ileus may be greatly reduced when all of the above are combined in a multimodal rehabilitation strategy.
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Affiliation(s)
- K Holte
- Department of Surgical Gastroenterology, Hvidovre University Hospital, Denmark
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Moojen TM, Van Gulik TM, Hoek FJ, Gouma DJ, Tytgat GN, Boeckxstaens GE. Possible role of nitric oxide in postoperative ileus: a comparative study. Neurogastroenterol Motil 1999; 11:403-8. [PMID: 10520171 DOI: 10.1046/j.1365-2982.1999.00158.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
In the present study, the possible involvement of nitric oxide (NO) in the pathogenesis of postoperative ileus was investigated indirectly by measuring nitrate, a stabile metabolite of NO. Plasma levels and 24-h urinary excretion of nitrate and nitrite were determined in the peri-operative period in three different groups of patients undergoing surgery: group 1 (LT, n=11) underwent a laparotomy, group 2 (LS, n=12) underwent a laparoscopic procedure, whereas group 3 underwent an extra-abdominal procedure (EA, n=9). Duration of postoperative ileus was assessed clinically using first occurrence of flatus and defaecation as the end of the period of ileus. Postoperative ileus lasted significantly longer in the LT group (first flatus after 3.0 [3.0-4.0] days) compared with the LS (1.0 [1.0-2.0] days) and EA (1.0 [1.0-3.0] days) groups. Urinary nitrate excretion increased significantly in the LT and EA groups during the first 24 h after surgery (from 797.0 [214.0-810.0] and 551.5 [438.3-1215.8] to 2079.0 [889.0-4644.0] and 1102.5 [315.3-1238. 0] micromol/24 h, median [IQR]), but normalized before the end of postoperative ileus. Plasma levels of nitrate were unchanged after surgery, whereas CRP levels were significantly increased in all groups (LT > LS=EA). In the first 24 h following surgery, urinary nitrate excretion is increased, suggesting increased endogenous synthesis of NO postoperatively. As no correlation was found between urinary nitrate excretion and duration of postoperative ileus, we conclude that assessment of nitrate has no value in predicting clinical outcome after surgery.
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Affiliation(s)
- T M Moojen
- Department of Surgery, Academic Medical Center, University of Amsterdam, The Netherlands
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Affiliation(s)
- J S Thompson
- Department of Surgery, University of Nebraska Medical Center, Omaha 68198-3280, USA
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Brown TA, McDonald J, Williard W. A prospective, randomized, double-blinded, placebo-controlled trial of cisapride after colorectal surgery. Am J Surg 1999; 177:399-401. [PMID: 10365879 DOI: 10.1016/s0002-9610(99)00071-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The predominant factor prolonging hospitalization and delaying oral intake after colorectal surgery continues to be return of large bowel function. We investigated the effect of the cisapride on postoperative bowel motility. METHODS Patients were started on cisapride versus a placebo on postoperative day 1 after colorectal surgery. Endpoints included the time to patients' first bowel movement, time of advancement to regular diet, time of hospitalization, and cost analysis. Results were analyzed using a Mann-Whitney test. RESULTS Thirty-five patients were entered in the study, consisting of 17 in the cisapride group and 18 in the placebo group. The median time to first bowel movement, advancement of diet, and hospital discharge was 1 day less in the cisapride group compared with the placebo group (P <0.05). There was a substantial cost savings in the study group. CONCLUSIONS Cisapride use results in statistically significant improvement in postoperative bowel motility. Cisapride should be added as adjunct treatment in postoperative care after colorectal surgery.
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Affiliation(s)
- T A Brown
- General Surgery Service, Madigan Army Medical Center, Tacoma, Washington 98431-5000, USA
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Bungard TJ, Kale-Pradhan PB. Prokinetic agents for the treatment of postoperative ileus in adults: a review of the literature. Pharmacotherapy 1999; 19:416-23. [PMID: 10212012 DOI: 10.1592/phco.19.6.416.31040] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Metoclopramide, cisapride, and erythromycin are commonly administered to reduce the duration of postoperative ileus (POI). As these agents are not without potential adverse effects, their efficacy in shortening the duration of POI should be evaluated. The etiology of POI is not well understood and therefore the precise treatment is unclear. Nasogastric suction is the mainstay of therapy, and management of fluid and electrolyte imbalances is crucial. The role of prokinetic agents is less understood. Available literature evaluating these drugs specifically for POI were reviewed, but results are confounded by issues such as sample size, variability in types of operations performed, and insensitive end points (flatus, bowel sounds). No literature supports reducing the duration of POI with metoclopramide, and limited data show benefit with cisapride. Data evaluating erythromycin are sparse, and the drug is believed to be ineffective. Domperidone, a prokinetic agent not available in the United States, has not been evaluated in POI. Due to these limitations, treatment remains largely supportive with a limited role for prokinetic agents.
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Affiliation(s)
- T J Bungard
- Department of Medicine, Division of Cardiology, University of Alberta, Edmonton, Canada
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Lander A, Redkar R, Nicholls G, Lawson A, Choudhury SR, Corkery JJ, Gornall P, Buick RG, Booth IW. Cisapride reduces neonatal postoperative ileus: randomised placebo controlled trial. Arch Dis Child Fetal Neonatal Ed 1997; 77:F119-22. [PMID: 9377133 PMCID: PMC1720698 DOI: 10.1136/fn.77.2.f119] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
AIM To assess the efficacy of cisapride in reducing ileus persisting to the tenth postoperative day after neonatal abdominal surgery. METHODS A prospective, randomised, double blind trial comparing rectal cisapride (1.4-2.3 mg/kg/day) with placebo over seven days was undertaken in 33 neonates. RESULTS Seven of 12 (58%) patients receiving placebo and eight of 11 (73%) receiving cisapride achieved a first sustained feed during treatment. Of those receiving cisapride, the first sustained feed occurred at 2.3 days (SEM 0.6) compared with 4.7 days (SEM 0.8) with placebo. By the seventh day the mean daily net enteral balance was 69 (SEM 18) ml/kg in the cisapride subgroup and 17 (SEM 8) ml/kg for those receiving placebo. Stool was passed on 6.3 (SEM 0.4) treatment days in the cisapride subgroup compared with 4.1 (SEM 1.0) treatment days in the placebo subgroup. CONCLUSION Cisapride is effective in neonates with a prolonged ileus after abdominal surgery.
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Affiliation(s)
- A Lander
- Department of Paediatric Surgery, Children's Hospital, Birmingham.
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20
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A pilot study of the effect of cisapride on gastric emptying in patients with chronic gastroparesis after highly selective vagotomy. Curr Ther Res Clin Exp 1996. [DOI: 10.1016/s0011-393x(96)80124-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Roberts JP, Benson MJ, Rogers J, Deeks JJ, Wingate DL, Williams NS. Effect of cisapride on distal colonic motility in the early postoperative period following left colonic anastomosis. Dis Colon Rectum 1995; 38:139-45. [PMID: 7851167 DOI: 10.1007/bf02052441] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE This study was designed to investigate the modulatory effect of cisapride on colonic motility in the postoperative period. METHODS A prospective, double-blind, randomized, placebo-controlled trial of 14 patients undergoing left colonic anastomosis was carried out. Manometric probes were positioned with transducers on either side of the anastomosis, and colonic activity was recorded continuously for a median of 98 (range, 72-144) hours using an ambulatory system. Quantitative indices of motility were calculated with an automated analysis program. RESULTS Isolated waveform activity returned at a median of 1.8 (interquartile range, 1-3) hours and motor complex activity at 24 (interquartile range, 19-30) hours in the placebo group and at similar times in the cisapride group. All motility variables except mean amplitude increased significantly with time in both groups. In the cisapride group the motility index was significantly increased compared with the placebo group (P = 0.03), resulting from an increase in percentage duration of activity (P = 0.002). Activity index, mean amplitude of waveforms, and number of waves greater than 50 cm H2O did not differ between groups. In contrast to placebo, cisapride significantly increased the median number of waves greater than 13 cm H2O and percentage duration of activity distal to the anastomosis compared with proximally. The return of bowel sounds (median, 43, interquartile range, 24-48 hours vs. 67, 29-69 hours; P = 0.2) or first passage of flatus (78, 54-94 hours vs. 94, 81-105 hours; P = 0.1) did not differ between groups. CONCLUSIONS Although cisapride may have a differential effect on the colon proximal and distal to an anastomosis and significantly increases some indices of motility in the early postoperative period, these are unlikely to be of any clinical relevance.
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Affiliation(s)
- J P Roberts
- Surgical Research Unit, London Hospital Medical School, Whitechapel, United Kingdom
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22
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Benson MJ, Roberts JP, Wingate DL, Rogers J, Deeks JJ, Castillo FD, Williams NS. Small bowel motility following major intra-abdominal surgery: the effects of opiates and rectal cisapride. Gastroenterology 1994; 106:924-36. [PMID: 8143997 DOI: 10.1016/0016-5085(94)90751-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND/AIMS Human small bowel motility is altered after laparotomy. Opiate analgesia is a possible cause of these alterations, and cisapride is a potential therapy. METHODS Continuous proximal small bowel manometry was performed for up to 92 hours in 23 patients after major intra-abdominal surgery. They were treated with rectal cisapride (30 mg three times daily) or placebo until the clinical resolution of ileus. Small bowel manometry was performed for 30 hours in 5 volunteers receiving 1 mg/kg meperidine over 3 hours. RESULTS Phase III activity was present within 3 hours of the end of surgery in all patients. Initially, the migrating motor complex (MMC) period was markedly reduced (mean, 22 minutes) but gradually increased. Phase II activity was absent until a median of 40 hours had elapsed. Phase III contractile amplitude was markedly attenuated in the jejunum, in contrast to that in the duodenum, presumably as a result of dilatation and/or altered tone, increasing to normal by 72 hours. In the volunteer group, although the MMC period was reduced by meperidine, it remained significantly greater than that of the placebo patient group for approximately 48 hours and phase II was reduced but not eliminated. Cisapride induced some changes in motor activity but did not accelerate the recovery of normal motility. Clinical outcome, assessed by the return of bowel sounds and passage of flatus, was accelerated by cisapride, but the trend was not significant (P = 0.11). CONCLUSIONS This is the first published study using prolonged manometry to show the gradual evolution of small bowel motor activity after major intra-abdominal surgery. The findings suggest that surgery decreases the MMC period to the equivalent of the absolute refractory period, thereby eliminating phase II, which returns as the MMC period lengthens. Cisapride, at the dosage given, confers only modest benefit.
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Affiliation(s)
- M J Benson
- Gastrointestinal Science Research Unit, London Hospital Medical College, England
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Bowling TE. Does disorder of gastrointestinal motility affect food intake in the post-surgical patient? Proc Nutr Soc 1994; 53:151-7. [PMID: 8029224 DOI: 10.1079/pns19940018] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
In summary, POI is a predictable event with actual return of bowel function preceding clinically detectable signs of function by at least 24 h. All parts of the gastrointestinal tract are affected, but small-intestinal function returns first, probably as early as 4-8 h after surgery in many cases. The timing of restarting feeding could be earlier than current practice would suggest, and because of the more rapid recovery of small-intestinal function it could be argued that post-pyloric feeding, at least in the first 24-48 h, may be preferable. While a policy of refeeding only when bowel function is clinically detectable is acceptable for many patients, there are certainly some who would benefit from feeding at an earlier stage. Parenteral feeding is expensive and a greater knowledge of the mechanisms underlying POI may lead clinicians to different and perhaps more appropriate methods of management.
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Affiliation(s)
- T E Bowling
- Department of Gastroenterology and Nutrition, Central Middlesex Hospital, London
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Hallerbäck B, Bergman B, Bong H, Ekström P, Glise H, Lundgren K, Risberg O. Cisapride in the treatment of post-operative ileus. Aliment Pharmacol Ther 1991; 5:503-11. [PMID: 1793781 DOI: 10.1111/j.1365-2036.1991.tb00519.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The effect of cisapride on duration of post-operative ileus after surgery was investigated in a randomized, double-blind, placebo-controlled study. Patients undergoing elective upper gastrointestinal (n = 47) or colonic (n = 22) surgery were pre-operatively randomly allocated to treatment with either cisapride 30 mg t.d.s., by rectal administration, or placebo. Treatment started exactly 48 h after surgery if the patient at this time had not passed stool. Time to passage of first stool after surgery was estimated. Mean time to passage of stool was 85 (32) h (s.d.) for cisapride-treated and 91 (43) h for placebo-treated patients. No difference between the treatment groups was noted. Treatment with cisapride did not shorten the duration of postoperative ileus after either upper gastrointestinal or colonic surgery.
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Affiliation(s)
- B Hallerbäck
- Department of Surgery, Northern Alvsborg Hospital, Trollhättan, Sweden
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GEEST J, VLAMINCK K, MUYLLE E, DEPREZ P, SUSTRONCK B, PICAVET MT. A clinical study of cisapride in horses after colic surgery. EQUINE VET EDUC 1991. [DOI: 10.1111/j.2042-3292.1991.tb01501.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Tollesson PO, Cassuto J, Rimbäck G, Faxén A, Bergman L, Mattsson E. Treatment of postoperative paralytic ileus with cisapride. Scand J Gastroenterol 1991; 26:477-82. [PMID: 1871540 DOI: 10.3109/00365529108998569] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The effect of cisapride on postoperative colonic motility was studied in 40 patients undergoing cholecystectomy under randomized, double-blind conditions. The patients received 10 mg of cisapride or placebo by intravenous injection starting on the day of surgery and repeated every 12 h until the 3rd postoperative day. The return of propagative motility in the colon was visualized by means of radiopaque markers and serial abdominal radiographs. Cisapride induced a significantly earlier return of propulsive motility in the right colon, as indicated by the propagation of markers from the ascending colon to the transverse colon (p less than 0.05). Radiopaque markers reached the descending colon (p less than 0.05) and the rectosigmoid colon (p less than 0.05) significantly earlier in the cisapride group than in controls. The first passage of feces occurred significantly earlier in cisapride-treated patients than in controls (p less than 0.05). The first passage of gas after surgery did not differ significantly between the groups. Our results suggest that cisapride can be used to induce earlier return of propagative motility in the colon after major abdominal surgery.
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Affiliation(s)
- P O Tollesson
- Dept of Radiology, Central Hospital, Mölndal, Sweden
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MacColl C, MacCannell KL, Baylis B, Lee SS. Treatment of acute colonic pseudoobstruction (Ogilvie's syndrome) with cisapride. Gastroenterology 1990; 98:773-6. [PMID: 2298376 DOI: 10.1016/0016-5085(90)90301-g] [Citation(s) in RCA: 57] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A 73-yr-old white woman admitted with lobar pneumonia and congestive heart failure developed progressive colonic pseudoobstruction (Ogilvie's syndrome) 2 days after admission which was unrelieved by diatrizoate meglumine (Gastrografin, Squibb Canada, Montreal) enema and rectal tube. Cisapride, a new gastrointestinal prokinetic agent, was administered intravenously with full resolution of the syndrome. To the authors' knowledge, this is the first reported case of successful treatment of acute colonic pseudoobstruction with cisapride.
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Affiliation(s)
- C MacColl
- Department of Medicine, University of Calgary, Alberta, Canada
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Abstract
Postoperative ileus follows any operation. Although worsened if the peritoneum is entered, the length and duration of surgery does not influence the severity of postoperative ileus. Inhibitory alpha 2-adrenergic reflexes with peptidergic afferents contribute to postoperative ileus. Clinically, treatment of ileus centers around symptomatic relief with nasogastric suction. Trials of adrenergic blockade combined with cholinergic stimulation have met with limited success. Prokinetic drugs have not been proved effective in the treatment of this disorder. Two types of ileus exist: postoperative and paralytic. Postoperative ileus resolves spontaneously after two to three days, and probably reflects inhibition of colonic motility. Paralytic ileus is more severe, last more than three days, and seems to represent inhibition of small bowel activity. No discrete structural changes cause postoperative ileus and the role of peptidergic neuronal systems of the enteric nervous system has not been elucidated. Possible central or humoral mechanisms have not been studied extensively. The possible direct inhibition of enteric or spinal nerves by anesthetic agents not cleared from these tissues remains to be studied. Also in need of study is the potential alteration of neurotransmitter receptor activity within the enteric nervous plexus after manipulation of the bowel.
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Affiliation(s)
- E H Livingston
- Surgical Service, West Los Angeles Veterans Administration Medical Center 90073
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Abstract
Attempts have previously been made to reduce adhesion formation by promoting early intestinal motility. The prokinetic agent Cisapride was used in an animal model of end-to-end large bowel anastomoses. Twenty Wistar rats receiving Cisapride 1 mg/kg subcutaneously (sc) twice daily for two days post-operatively were compared with 20 controls receiving saline 0.2 mL in a similar regimen. The points of adhesion of the anastomosis to the following structures were enumerated: tubal fat; mesentery; omentum; caecum; small bowel; and abdominal wall. The treatment group had significantly fewer adhesions: 2.8 +/- 0.9 v 4.3 +/- 1.0. This was mainly in the number of small bowel attachments, 3.8% compared with 37.8%. The study was repeated using small bowel anastomoses. Cisapride again reduced the number of adhesions compared with controls: 2.1 +/- 0.4 v 4.2 +/- 1.4. Cisapride therapy resulted in greater post-operative stool weights and food consumption: control, 3.87 +/- 1.1 stool, 17.04 +/- 4.3 g food; Cisapride 4.43 +/- 0.9 g stool, 19.8 +/- 4.7 g food. The enhanced motility did not affect the anastomotic strength of the small bowel; bursting pressures at a constant inflation rate of 1.1 mL/min were: control 212.8 +/- 56.0 mmHg; Cisapride, 215.8 +/- 58.9 mmHg (NS).
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Affiliation(s)
- R G Springall
- Department of Paediatric Surgery, Institute of Child Health, London, England
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