Prokinetic effect of erythromycin after colorectal surgery: randomized, placebo-controlled, double-blind study

Prokinetics-safety and efficacy: The European Society of Neurogastroenterology and Motility/The American Neurogastroenterology and Motility Society expert review

BACKGROUND

Prokinetics are a class of pharmacological drugs designed to improve gastrointestinal (GI) motility, either regionally or across the whole gut. Each drug has its merits and drawbacks, and based on current evidence as high-quality studies are limited, we have no clear recommendation on one class or other. However, there remains a large unmet need for both regionally selective and/or globally acting prokinetic drugs that work primarily intraluminally and are safe and without systemic side effects.

PURPOSE

Here, we describe the strengths and weaknesses of six classes of prokinetic drugs, including their pharmacokinetic properties, efficacy, safety and tolerability and potential indications.

Postoperative ileus after digestive surgery: Network meta-analysis of pharmacological intervention

AIMS

Several medicinal treatments for avoiding postoperative ileus (POI) after abdominal surgery have been evaluated in randomized controlled trials (RCTs). This network meta-analysis aimed to explore the relative effectiveness of these different treatments on ileus outcome measures.

METHODS

A systematic literature review was performed to identify RCTs comparing treatments for POI following abdominal surgery. A Bayesian network meta-analysis was performed. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis.

RESULTS

A total of 38 RCTs were included in this network meta-analysis reporting on 6371 patients. Our network meta-analysis shows that prokinetics significantly reduce the duration of first gas (mean difference [MD] = 16 h; credible interval -30, -3.1; surface under the cumulative ranking curve [SUCRA] 0.418), duration of first bowel movements (MD = 25 h; credible interval -39, -11; SUCRA 0.25) and duration of postoperative hospitalization (MD -1.9 h; credible interval -3.8, -0.040; SUCRA 0.34). Opioid antagonists are the only treatment that significantly improve the duration of food recovery (MD -19 h; credible interval -26, -14; SUCRA 0.163).

CONCLUSION

Based on our meta-analysis, the 2 most consistent pharmacological treatments able to effectively reduce POI after abdominal surgery are prokinetics and opioid antagonists. The absence of clear superiority of 1 treatment over another highlights the limits of the pharmacological principles available.

Effect of Acupoint Stimulation on Improving Gastrointestinal Motility in Patients After Gastrectomy: A Systematic Review and Meta-Analysis

Introduction: Gastrointestinal immobility is experienced by many patients who undergo gastric surgery. This complication delays enteral nutrition, prolongs hospitalization, and causes discomfort. Acupoint stimulation is a popular alternative nonpharmacological treatment for gastrointestinal immobility. This study aimed to explore the effects of acupoint stimulation on gastrointestinal immobility after gastrectomy. Design: Systematic review and meta-analysis. Methods: Databases (PubMed, Cochrane, Joanna Briggs Institute EBP Database, Medline, CINAHL Complete, and Airiti library) were searched from their inception to April 2022 for relevant articles. Articles in Chinese and English were included, without limitations on year, region, or country. The inclusion criteria were studies with participants >18 years of age, postgastric surgery, and hospitalization. In addition, randomized controlled trials (RCTs) were included. Data were analyzed using random effects models, and data heterogeneity was investigated using subgroup analysis. Meta-analysis was performed using Review Manager 5.4 software. Results: We included 785 participants from six studies. Invasive and noninvasive acupoint stimulation reduced the time of gastrointestinal mobility better than usual care. In the control group, the time of first flatus was 43.56 ± 9.57 h to 108 ± 19.2 h, and the time of first defecation was 77.27 ± 22.67 h to 139.2 ± 24 h. In the experimental group, the time of first flatus and defecation was 36.58 ± 10.75 h to 79.97 ± 37.31 h and 70.56 ± 15.36 h to 108.55 ± 10.75 h, respectively. Subgroup analysis showed that invasive acupoint stimulation with acupuncture reduced the time of first flatus and defecation to 15.03 h (95% confidence interval [CI] = -31.06 to 1.01) and 14.12 h (95% CI = -32.78 to 4.54), respectively. Noninvasive acupoint stimulation, including acupressure and transcutaneous electrical acupoint stimulation (TEAS), reduced the time of first flatus and defecation to 12.33 h and (95% CI = -20.59 to -4.06) and 12.20 h (95% CI = -24.92 to 0.52), respectively. Conclusions: Acupoint stimulation improved the gastrointestinal immobility of postgastrectomy. In the included RCT articles, invasive and noninvasive stimulations were effective. However, noninvasive acupoint stimulation, such as with TEAS and acupressure, was more efficient and convenient than invasive stimulation. Overall, health care professionals with adequate training or under the supervision of an acupuncturist can effectively perform acupoint stimulation to improve the quality of postgastrectomy care. They can select commonly used and effective acupoints to enhance gastrointestinal motility. Clinical relevance: Acupoint stimulation, such as acupressure, electrical acupoint stimulation, or acupuncture, can be included in postgastrectomy routine care to improve gastrointestinal motility and reduce abdominal discomfort.

Gastrointestinal Dysmotility in Critically Ill Patients: Bridging the Gap Between Evidence and Common Misconceptions

Disruption of normal gastrointestinal (GI) function in critical illness is linked to increased morbidity and mortality, and GI dysmotility is frequently observed in patients who are critically ill. Despite its high prevalence, the diagnosis and management of GI motility problems in the intensive care unit remain very challenging, given that critically ill patients often cannot verbalize symptoms and the general lack of understanding of underlying pathophysiology. Common clinical presentations of GI dysmotility issues among critically ill patients include: (1) high gastric residual volumes, acid reflux, and vomiting, (2) abdominal distention, and (3) diarrhea. In this review, we discuss the differential diagnosis for intensive care unit patients with symptoms and signs concerning GI motility issues. There are many myths and longstanding misconceptions about the diagnosis and management of GI dysmotility in critical illness. Here, we uncover these myths and discuss relevant evidence in each subject area, with the goal of re-conceptualizing GI motility disorders in critical care and providing evidence-based recommendations for clinical care.

Reducing ileus after colorectal surgery: A network meta-analysis of therapeutic interventions

BACKGROUND

Several treatment strategies for avoiding post-operative ileus have been evaluated in randomised controlled trials. This network meta-analysis aimed to explore the relative effectiveness of these different therapeutic interventions on ileus outcome measures.

METHODS

A systematic literature review was performed to identify randomized controlled trials (RCTs) comparing treatments for post-operative ileus following colorectal surgery. A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis.

RESULTS

A total of 48 randomised controlled trials were included in this network meta-analysis reporting on 3614 participants. Early feeding was found to be the best treatment for time to solid diet tolerance and length of hospital stay with a probability of P = 0.96 and P = 0.47, respectively. Early feeding resulted in significantly shorter time to solid diet tolerance (Mean Difference (MD) 58.85 h; 95% Credible Interval (CrI) -73.41, -43.15) and shorter length of hospital stay (MD 2.33 days; CrI -3.51, -1.18) compared to no treatment. Epidural analgesia was ranked best treatment for time to flatus (P = 0.29) and time to stool (P = 0.268). Epidural analgesia resulted in significantly shorter time to flatus (MD -18.88 h; CrI -33.67, -3.44) and shorter time to stool (MD -26.05 h; 95% CrI -66.42, 15.65) compared to no intervention. Gastrograffin was ranked best treatment to avoid the requirement for post-operative nasogastric tube insertion (P = 0.61) however demonstrated limited efficacy (OR 0.50; CrI 0.143, 1.621) compared to no intervention. Nasogastric and nasointestinal tube insertion, probiotics, and acupuncture were found to be least efficacious as interventions to reduce ileus.

CONCLUSION

This network meta-analysis identified early feeding as the most efficacious therapeutic intervention to reduce post-operative ileus in patients undergoing colorectal surgery, in addition to highlighting other therapies that require further investigation by high quality study. In patients undergoing colorectal surgery, emphasis should be placed on early feeding as soon as can be appropriately initiated to support the return of gastrointestinal motility.

A woman with adult-onset Still's disease and acute intestinal pseudo-obstruction

Adult-onset Still's disease may cause intestinal pseudo-obstruction via a cytokine storm. Early diagnosis and treatment are the key for patient survival before the development of serious complications such as macrophage activation syndrome.

Postoperative Ileus and Postoperative Gastrointestinal Tract Dysfunction: Pathogenic Mechanisms and Novel Treatment Strategies Beyond Colorectal Enhanced Recovery After Surgery Protocols

Postoperative ileus (POI) and postoperative gastrointestinal tract dysfunction (POGD) are well-known complications affecting patients undergoing intestinal surgery. GI symptoms include nausea, vomiting, pain, abdominal distention, bloating, and constipation. These iatrogenic disorders are associated with extended hospitalizations, increased morbidity, and health care costs into the billions and current therapeutic strategies are limited. This is a narrative review focused on recent concepts in the pathogenesis of POI and POGD, pipeline drugs or approaches to treatment. Mechanisms, cellular targets and pathways implicated in the pathogenesis include gut surgical manipulation and surgical trauma, neuroinflammation, reactive enteric glia, macrophages, mast cells, monocytes, neutrophils and ICC's. The precise interactions between immune, inflammatory, neural and glial cells are not well understood. Reactive enteric glial cells are an emerging therapeutic target that is under intense investigation for enteric neuropathies, GI dysmotility and POI. Our review emphasizes current therapeutic strategies, starting with the implementation of colorectal enhanced recovery after surgery protocols to protect against POI and POGD. However, despite colorectal enhanced recovery after surgery, it remains a significant medical problem and burden on the healthcare system. Over 100 pipeline drugs or treatments are listed in Clin.Trials.gov. These include 5HT4R agonists (Prucalopride and TAK 954), vagus nerve stimulation of the ENS-macrophage nAChR cholinergic pathway, acupuncture, herbal medications, peripheral acting opioid antagonists (Alvimopen, Methlnaltexone, Naldemedine), anti-bloating/flatulence drugs (Simethiocone), a ghreline prokinetic agonist (Ulimovelin), drinking coffee, and nicotine chewing gum. A better understanding of the pathogenic mechanisms for short and long-term outcomes is necessary before we can develop better prophylactic and treatment strategies.

Promotility agents for the treatment of ileus in adult surgical patients: A practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Ileus is a common challenge in adult surgical patients with estimated incidence to be 17% to 80%. The main mechanisms of the postoperative ileus pathophysiology are fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch, and inflammation. Management includes addressing the underlying cause and supportive care. Multiple medical interventions have been proposed, but effectiveness is uncertain. A working group of the Eastern Association for the Surgery of Trauma aimed to evaluate the effectiveness of metoclopramide, erythromycin, and early enteral nutrition (EEN) on ileus in adult surgical patients and to develop recommendations applicable in a daily clinical practice.

METHODS

Literature search identified 45 articles appropriate for inclusion. The Grading of Recommendations Assessment, Development and Evaluation methodology was applied to evaluate the effect of metoclopramide, erythromycin, and EEN on the resolution of ileus in adult surgical patients based on selected outcomes: return of normal bowel function, attainment of enteral feeding goal, and hospital length of stay. The recommendations were made based on the results of a systematic review, a meta-analysis, and evaluation of levels of evidence.

RESULTS

The level of evidence for all PICOs was assessed as low. Neither metoclopramide nor erythromycin were effective in expediting the resolution of ileus. Analyses of 32 randomized controlled trials showed that EEN facilitates return of normal bowel function, achieving enteral nutrition goals, and reducing hospital length of stay.

CONCLUSION

In patients who have undergone abdominal surgery, we strongly recommend EEN to expedite resolution of Ileus, but we cannot recommend for or against the use of either metoclopramide or erythromycin to hasten the resolution of ileus in these patients.

LEVEL OF EVIDENCE

Type of Study Therapeutic, level II.

Adverse events in people taking macrolide antibiotics versus placebo for any indication

BACKGROUND

Macrolide antibiotics (macrolides) are among the most commonly prescribed antibiotics worldwide and are used for a wide range of infections. However, macrolides also expose people to the risk of adverse events. The current understanding of adverse events is mostly derived from observational studies, which are subject to bias because it is hard to distinguish events caused by antibiotics from events caused by the diseases being treated. Because adverse events are treatment-specific, rather than disease-specific, it is possible to increase the number of adverse events available for analysis by combining randomised controlled trials (RCTs) of the same treatment across different diseases.

OBJECTIVES

To quantify the incidences of reported adverse events in people taking macrolide antibiotics compared to placebo for any indication.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), which includes the Cochrane Acute Respiratory Infections Group Specialised Register (2018, Issue 4); MEDLINE (Ovid, from 1946 to 8 May 2018); Embase (from 2010 to 8 May 2018); CINAHL (from 1981 to 8 May 2018); LILACS (from 1982 to 8 May 2018); and Web of Science (from 1955 to 8 May 2018). We searched clinical trial registries for current and completed trials (9 May 2018) and checked the reference lists of included studies and of previous Cochrane Reviews on macrolides.

SELECTION CRITERIA

We included RCTs that compared a macrolide antibiotic to placebo for any indication. We included trials using any of the four most commonly used macrolide antibiotics: azithromycin, clarithromycin, erythromycin, or roxithromycin. Macrolides could be administered by any route. Concomitant medications were permitted provided they were equally available to both treatment and comparison groups.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted and collected data. We assessed the risk of bias of all included studies and the quality of evidence for each outcome of interest. We analysed specific adverse events, deaths, and subsequent carriage of macrolide-resistant bacteria separately. The study participant was the unit of analysis for each adverse event. Any specific adverse events that occurred in 5% or more of any group were reported. We undertook a meta-analysis when three or more included studies reported a specific adverse event.

MAIN RESULTS

We included 183 studies with a total of 252,886 participants (range 40 to 190,238). The indications for macrolide antibiotics varied greatly, with most studies using macrolides for the treatment or prevention of either acute respiratory tract infections, cardiovascular diseases, chronic respiratory diseases, gastrointestinal conditions, or urogynaecological problems. Most trials were conducted in secondary care settings. Azithromycin and erythromycin were more commonly studied than clarithromycin and roxithromycin.Most studies (89%) reported some adverse events or at least stated that no adverse events were observed.Gastrointestinal adverse events were the most commonly reported type of adverse event. Compared to placebo, macrolides caused more diarrhoea (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.34 to 2.16; low-quality evidence); more abdominal pain (OR 1.66, 95% CI 1.22 to 2.26; low-quality evidence); and more nausea (OR 1.61, 95% CI 1.37 to 1.90; moderate-quality evidence). Vomiting (OR 1.27, 95% CI 1.04 to 1.56; moderate-quality evidence) and gastrointestinal disorders not otherwise specified (NOS) (OR 2.16, 95% CI 1.56 to 3.00; moderate-quality evidence) were also reported more often in participants taking macrolides compared to placebo.The number of additional people (absolute difference in risk) who experienced adverse events from macrolides was: gastrointestinal disorders NOS 85/1000; diarrhoea 72/1000; abdominal pain 62/1000; nausea 47/1000; and vomiting 23/1000.The number needed to treat for an additional harmful outcome (NNTH) ranged from 12 (95% CI 8 to 23) for gastrointestinal disorders NOS to 17 (9 to 47) for abdominal pain; 19 (12 to 33) for diarrhoea; 19 (13 to 30) for nausea; and 45 (22 to 295) for vomiting.There was no clear consistent difference in gastrointestinal adverse events between different types of macrolides or route of administration.Taste disturbances were reported more often by participants taking macrolide antibiotics, although there were wide confidence intervals and moderate heterogeneity (OR 4.95, 95% CI 1.64 to 14.93; I² = 46%; low-quality evidence).Compared with participants taking placebo, those taking macrolides experienced hearing loss more often, however only four studies reported this outcome (OR 1.30, 95% CI 1.00 to 1.70; I² = 0%; low-quality evidence).We did not find any evidence that macrolides caused more cardiac disorders (OR 0.87, 95% CI 0.54 to 1.40; very low-quality evidence); hepatobiliary disorders (OR 1.04, 95% CI 0.27 to 4.09; very low-quality evidence); or changes in liver enzymes (OR 1.56, 95% CI 0.73 to 3.37; very low-quality evidence) compared to placebo.We did not find any evidence that appetite loss, dizziness, headache, respiratory symptoms, blood infections, skin and soft tissue infections, itching, or rashes were reported more often by participants treated with macrolides compared to placebo.Macrolides caused less cough (OR 0.57, 95% CI 0.40 to 0.80; moderate-quality evidence) and fewer respiratory tract infections (OR 0.70, 95% CI 0.62 to 0.80; moderate-quality evidence) compared to placebo, probably because these are not adverse events, but rather characteristics of the indications for the antibiotics. Less fever (OR 0.73, 95% 0.54 to 1.00; moderate-quality evidence) was also reported by participants taking macrolides compared to placebo, although these findings were non-significant.There was no increase in mortality in participants taking macrolides compared with placebo (OR 0.96, 95% 0.87 to 1.06; I² = 11%; low-quality evidence).Only 24 studies (13%) provided useful data on macrolide-resistant bacteria. Macrolide-resistant bacteria were more commonly identified among participants immediately after exposure to the antibiotic. However, differences in resistance thereafter were inconsistent.Pharmaceutical companies supplied the trial medication or funding, or both, for 91 trials.

AUTHORS' CONCLUSIONS

The macrolides as a group clearly increased rates of gastrointestinal adverse events. Most trials made at least some statement about adverse events, such as "none were observed". However, few trials clearly listed adverse events as outcomes, reported on the methods used for eliciting adverse events, or even detailed the numbers of people who experienced adverse events in both the intervention and placebo group. This was especially true for the adverse event of bacterial resistance.

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.

Postoperative ileus following major colorectal surgery

BACKGROUND

Postoperative ileus (POI) is characterized by delayed gastrointestinal recovery following surgery. Current knowledge of pathophysiology, clinical interventions and methodological challenges was reviewed to inform modern practice and future research.

METHODS

A systematic search of MEDLINE and Embase databases was performed using search terms related to ileus and colorectal surgery. All RCTs involving an intervention to prevent or reduce POI published between 1990 and 2016 were identified. Grey literature, non-full-text manuscripts, and reanalyses of previous RCTs were excluded. Eligible articles were assessed using the Cochrane tool for assessing risk of bias.

RESULTS

Of 5614 studies screened, 86 eligible articles describing 88 RCTs were identified. Current knowledge of pathophysiology acknowledges neurogenic, inflammatory and pharmacological mechanisms, but much of the evidence arises from animal studies. The most common interventions tested were chewing gum (11 trials) and early enteral feeding (11), which are safe but of unclear benefit for actively reducing POI. Others, including thoracic epidural analgesia (8), systemic lidocaine (8) and peripheral μ antagonists (5), show benefit but require further investigation for safety and cost-effectiveness.

CONCLUSION

POI is a common condition with no established definition, aetiology or treatment. According to current literature, minimally invasive surgery, protocol-driven recovery (including early feeding and opioid avoidance strategies) and measures to avoid major inflammatory events (such as anastomotic leak) offer the best chances of reducing POI.

Postoperative ileus: Pathophysiology, incidence, and prevention

Postoperative ileus (POI) is a major focus of concern for surgeons because it increases duration of hospitalization, cost of care, and postoperative morbidity. The definition of POI is relatively consensual albeit with a variable definition of interval to resolution ranging from 2 to 7 days for different authors. This variation, however, leads to non-reproducibility of studies and difficulties in interpreting the results. Certain risk factors for POI, such as male gender, advanced age and major blood loss, have been repeatedly described in the literature. Understanding of the pathophysiology of POI has helped combat and prevent its occurrence. But despite preventive and therapeutic efforts arising from such knowledge, 10 to 30% of patients still develop POI after abdominal surgery. In France, pharmacological prevention is limited by the unavailability of effective drugs. Perioperative nutrition is very important, as well as limitation of preoperative fasting to 6 hours for solid food and 2 hours for liquids, and virtually no fasting in the postoperative period. Coffee and chewing gum also play a preventive role for POI. The advent of laparoscopy has led to a significant improvement in the recovery of gastrointestinal function. Enhanced recovery programs, grouping together all measures for prevention or cure of POI by addressing the mechanisms of POI, has reduced the duration of hospitalization, morbidity and interval to resumption of transit.

A Double-Blinded Randomized Clinical Study on the Therapeutic Effect of Gastrografin in Prolonged Postoperative Ileus After Elective Colorectal Surgery

BACKGROUND

Postoperative ileus is a common problem with significant clinical and economic consequences. We hypothesized that Gastrografin may have therapeutic utility by accelerating the recovery of postoperative ileus after colorectal surgery. The aim of this trial was to study the impact of oral Gastrografin administration on postoperative prolonged ileus (PPI) after elective colorectal surgery.

METHODS

The main endpoint of this randomized, double-blinded, controlled trial was time of resolution of PPI. The secondary endpoints were overall hospital length of stay, time to start oral intake, time to first passage of flatus or stools, time of need of nasogastric tube, and need of parenteral nutrition. Included criteria were patients older than 18 years, operated for colonic neoplasia, inflammatory bowel disease, or diverticular disease. There were two treatments: Gastrografin administration and placebo. The sample size was calculated taking into account the average length of postoperative ileus after colorectal resection until tolerance to oral intake. Statistical analysis showed that 29 subjects in each group were needed.

RESULTS

Twenty-nine patients per group were randomized. Groups were comparable for age, gender, ASA Physical Status Classification System, stoma construction, and surgical technique. No statistical differences were observed in mean time to resolution between the two groups, 9.1 days (CI 95%, 6.51-11.68) in Gastrografin group versus 10.3 days (CI 6.96-10.29) in Placebo group (P = 0.878). Even if not statistically significant, time of resolution of PPI, overall length of stay, time of need of nasogastric tube, and time to tolerance of oral intake were shorter in the G group.

CONCLUSIONS

Gastrografin does not accelerate significantly the recovery of prolonged postoperative ileus after elective colorectal resection when compared with placebo. However, it seems to clinically improve all the analyzed variables.

Pharmacological management to prevent ileus in major abdominal surgery: a systematic review and meta-analysis

BACKGROUND

Prolonged ileus is a common complication following gastrointestinal surgery, with an incidence of up to 40 %. Investigations examining pharmacological treatment of ileus have proved largely disappointing; however, recently, several compounds have been shown to have benefited when used as prophylaxis to prevent ileus.

OBJECTIVE

This review aimed to evaluate the safety and efficacy of compounds which have been recently developed or repurposed to reduce bowel recovery time, thereby preventing ileus.

DATA SOURCES

Data were taken from a systematic review of the MEDLINE, EMBASE and Cochrane Library Databases, in addition to manual searching of reference lists up to April 2015. No limits were applied.

STUDY SELECTION

Only randomized trials were eligible for inclusion.

INTERVENTIONS

Opioid receptor antagonists, ghrelin receptor agonists and serotonin receptor agonists used for the prevention of postoperative ileus in gastrointestinal surgery.

MAIN OUTCOME MEASURES

Outcomes of time to first defecation, first flatus and composite bowel recovery endpoints (GI2 and GI3) were used to determine efficacy. Pooled treatment effects were presented as the standard mean difference or as hazard ratios alongside the corresponding 95 % confidence intervals. Risk of bias was assessed using the Cochrane risk of bias framework.

RESULTS

A total of 17 studies were included in the final analysis. The μ-opioid receptor antagonist alvimopan and serotonin receptor agonists appeared to significantly shorten the duration of ileus. The use of Ghrelin receptor agonists did not appear to have any effect in five trials. No publication bias was detected.

LIMITATIONS

Most of the trials were poorly reported and of mixed quality. Future studies must focus on the development of a set of core outcomes.

CONCLUSIONS

There is evidence to make a strong recommendation for the use of alvimopan in major gastrointestinal surgery to reduce postoperative ileus. Further randomized trials are required to establish whether serotonin receptor agonists are of use. Identifying a low-cost compound to promote bowel recovery following surgery could reduce complications and shorten duration of hospital admissions.

Interventions That Affect Gastrointestinal Motility in Hospitalized Adult Patients: A Systematic Review and Meta-Analysis of Double-Blind Placebo-Controlled Randomized Trials

Gastrointestinal (GI) dysmotility is a common complication in acute, critically ill, postoperative, and chronic patients that may lead to impaired nutrient delivery, poor clinical, and patient-reported outcomes. Several pharmacological and nonpharmacological interventions to treat GI dysmotility were investigated in dozens of clinical studies. However, they often yielded conflicting results, at least in part, because various (nonstandardized) definitions of GI dysmotility were used and methodological quality of studies was poor. While a universally accepted definition of GI dysmotility is yet to be developed, a systematic analysis of data derived from double-blind placebo-controlled randomized trials may provide robust data on absolute and relative effectiveness of various interventions as the study outcome (GI motility) was assessed in the least biased manner.To systematically review data from double-blind placebo-controlled randomized trials to determine and compare the effectiveness of interventions that affect GI motility.Three electronic databases (MEDLINE, SCOPUS, and EMBASE) were searched. A random effects model was used for meta-analysis. The summary estimates were reported as mean difference (MD) with the corresponding 95% confidence interval (CI).A total of 38 double-blind placebo-controlled randomized trials involving 2371 patients were eligible for inclusion in the systematic review. These studies investigated a total of 20 different interventions, of which 6 interventions were meta-analyzed. Of them, the use of dopamine receptor antagonists (MD, -8.99; 95% CI, -17.72 to -0.27; P = 0.04) and macrolides (MD, -26.04; 95% CI, -51.25 to -0.82; P = 0.04) significantly improved GI motility compared with the placebo group. The use of botulism toxin significantly impaired GI motility compared with the placebo group (MD, 5.31; 95% CI, -0.04 to 10.67; P = 0.05). Other interventions (dietary factors, probiotics, hormones) did not affect GI motility.Based on the best available data and taking into account the safety profile of each class of intervention, dopamine receptor antagonists and macrolides significantly improve GI motility and are medications of choice in treating GI dysmotility.

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.

Paralytic ileus induced by glyphosate intoxication successfully treated using Kampo medicine

Case

A 65-year-old woman ingested glyphosate-surfactant herbicide in an attempt to commit suicide. She experienced glyphosate intoxication associated with multiple organ failure and developed a paralytic ileus. Daijokito, a traditional Japanese Kampo medicine was given to the patient to improve constipation and psychological symptoms. Next, rikkunshito was given to increase her gastric motility. Finally, daikenchuto was given to improve overall digestive peristalsis.

Outcome

All abdominal symptoms ultimately improved after treatment with daikenchuto.

Conclusion

Kampo medicines may help improve abdominal symptoms associated with glyphosate intoxication in cases where modern medical treatment alone proves inadequate.

Postoperative ileus: mechanisms and future directions for research

Postoperative ileus (POI) is an abnormal pattern of gastrointestinal motility characterized by nausea, vomiting, abdominal distension and/or delayed passage of flatus or stool, which may occur following surgery. Postoperative ileus slows recovery, increases the risk of developing postoperative complications and confers a significant financial load on healthcare institutions. The aim of the present review is to provide a succinct overview of the clinical features and pathophysiological mechanisms of POI, with final comment on selected directions for future research.Terminology used when describing POI is inconsistent, with little differentiation made between the obligatory period of gut dysfunction seen after surgery ('normal POI') and the more clinically and pathologically significant entity of a 'prolonged POI'. Both normal and prolonged POI represent a fundamentally similar pathophysiological phenomenon. The aetiology of POI is postulated to be multifactorial, with principal mediators being inflammatory cell activation, autonomic dysfunction (both primarily and as part of the surgical stress response), agonism at gut opioid receptors, modulation of gastrointestinal hormone activity and electrolyte derangements. A final common pathway for these effectors is impaired contractility and motility and gut wall oedema. There are many potential directions for future research. In particular, there remains scope to accurately characterize the gastrointestinal dysfunction that underscores an ileus, development of an accurate risk stratification tool will facilitate early implementation of preventive measures and clinical appraisal of novel therapeutic strategies that target individual pathways in the pathogenesis of ileus warrant further investigation.

Sham feeding with chewing gum after elective colorectal resectional surgery: a randomized clinical trial

OBJECTIVE

To determine whether sham feeding with chewing gum improved gastrointestinal recovery after colorectal resection surgery, in the presence of routine postoperative feeding.

BACKGROUND

Sham feeding with chewing gum has been shown to accelerate the return of gut function after colorectal surgery. This study sought to determine whether sham feeding with gum, after colorectal resection, accelerates return of gastrointestinal function in patients on a rapid feeding enhanced recovery program.

METHODS

A randomized "two armed" controlled clinical trial was performed. Equal groups of open and laparoscopic colorectal resection surgical patients were recruited. Patients in the intervention arm received chewing gum 4 times a day postoperatively. All patients in the trial were placed on an established, standardized Enhanced Recovery After Surgery program. The primary outcome was time to return of gut function, assessed by time to flatus and first bowel motion. Secondary outcomes were time to tolerate diet, symptoms of ileus in the form of nausea, vomiting and distension, pain as assessed by analgesic consumption and visual analogue scales, complications, and length of hospital stay.

RESULTS

A total of 161 patients were recruited. Postoperative morbidity was equivalent between groups, with no complications related to gum chewing. There was no difference between groups with respect to the primary outcomes of time to flatus and bowel motion. There was less perception of pain in the intervention group on days 2 to 5, and no difference with respect to all other secondary outcomes.

CONCLUSIONS

Sham feeding with gum, after open and laparoscopic colorectal resectional surgery is safe, but does not hasten the return of gastrointestinal function in patients who receive accelerated postoperative feeding. (ACTRN12607000538448).

Defining postoperative ileus: results of a systematic review and global survey

BACKGROUND

There is a lack of an internationally accepted standardised clinical definition for postoperative ileus (POI). This has made it difficult to estimate incidence and identify risk factors and has compromised external validity of clinical trials.

AIM

To clarify terminology of POI and propose concise, clinically quantifiable definitions.

METHODS

A systematic review extracted definitions from randomised trials published between 1996 and 2011 investigating POI after abdominal surgery. This was followed by a global survey seeking opinions of those who have published in the field.

RESULTS

Definitions were extracted from 52 identified trials. Responses were received in the survey from 45 of 118 corresponding authors. Data were amalgamated to synthesise the following definitions: postoperative ileus (POI) "interval from surgery until passage of flatus/stool AND tolerance of an oral diet"; prolonged POI "two or more of nausea/vomiting, inability to tolerate oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation occurring on or after day 4 postoperatively without prior resolution of POI"; recurrent POI "two or more of nausea/vomiting, inability to tolerate oral diet over 24 h, absence of flatus over 24 h, distension, radiologic confirmation, occurring after apparent resolution of POI". Concordance of the latter two definitions with survey responses were ≥75 %.

CONCLUSION

We have proposed standardised endpoints for use in future studies to facilitate objective comparison of competing interventions.

A prospective randomized controlled trial of sugared chewing gum on gastrointestinal recovery after major colorectal surgery in patients managed with early enteral feeding

BACKGROUND

A number of small prospective studies with conflicting results have evaluated the effect of sugar-free chewing gum on postoperative GI recovery in patients initially maintained nil per os after major colorectal surgery.

OBJECTIVE

We sought to evaluate the effect of sugared chewing gum in combination with early enteral feeding on recovery of GI function after major colorectal surgery to ascertain any additive effects of this combination.

DESIGN

This was a randomized prospective study.

SETTING

This study was conducted at a single-institution tertiary referral center.

PATIENTS

Patients undergoing major colorectal surgery were included.

INTERVENTIONS

Patients were randomly assigned to sugared chewing gum (Gum) (instructed to chew 3 times daily; 45 minutes each time for 7 days postoperatively) or No Gum after major colorectal surgery.

MAIN OUTCOME MEASURES

The primary outcome measured was time to tolerating low residue diet without emesis for 24 hours. The secondary outcomes measured were time to flatus, time to bowel movement, postoperative hospital stay, postoperative pain, nausea, and appetite.

RESULTS

One hundred fourteen patients (60 No Gum; 54 Gum) were included in our analysis after randomization. There was no significant difference in time to tolerating a low-residue diet, time to flatus, time to bowel movement, length of postoperative hospital stay, postoperative complications, postoperative pain, nausea, or appetite between patients assigned to Gum or No Gum. There was an increased incidence of bloating, indigestion, and eructation in the Gum group (13%) in comparison with the No Gum group (2%) (p = 0.03).

LIMITATIONS

Study subjects and investigators were not blinded. Multiple types of operations may cause intergroup variability.

CONCLUSIONS

There does not appear to be any benefit to sugared chewing gum in comparison with no gum in patients undergoing major colorectal surgery managed with early feeding in the postoperative period. There may be increased incidence of bloating, indigestion, and eructation, possibly related to swallowed air during gum chewing.

The effect of erythromycin on gastrointestinal motility in subtotal gastrectomized patients

Purpose

Our objective was to determine the effect of erythromycin (EM) in improving gastrointestinal motility in subtotal gastrectomized patients. We used radio-opaque Kolomarks as an objective method. We conducted a prospective, controlled clinical trial study of 24 patients.

Methods

All patients underwent subtotal gastrectomy with 3 capsules containing Kolomarks (20 markers per 1 capsule) in the remnant stomach before anastomosis. From the day of the operation to the 2nd postoperative day, patients in the EM group began receiving 200 mg of EM intravenously for 30 minutes continuously. We counted the number of Kolomarks in the stomach, passed by stomach, in rectum, and in stool with serial simple abdominal X-ray films on the first postoperative day up to the 7th postoperative day.

Results

The study population included 14 patients in the control group and 10 patients in the EM group. The two study groups were compared in terms of their characteristics including age, gender, past medical history, cancer stage, and operation type. No significant differences were found for the demographics between the two groups. We only found a significant difference for the number of Kolomarks passed by the stomach on the 3rd postoperative day (P = 0.026).

Conclusion

Our results demonstrated that 200 mg of EM intravenous infusion during the postoperative period induced rapid gastric emptying, although it did not improve gastrointestinal motility for the entire gastrointestinal tract in subtotal gastrectomized patients.

Postoperative ileus: strategies for reduction

Postoperative Ileus (POI) is a frequent, frustrating occurrence for patients and surgeons after abdominal surgery. Despite significant research investigating how to reduce this multi-factorial phenomenon, a single strategy has not been shown to reduce POI's significant effects on length of stay (LOS) and hospital costs. Perhaps the most significant cause of POI is the use of narcotics for analgesia. Strategies that target inflammation and pain reduction such as NSAID use, epidural analgesia, and laparoscopic techniques will reduce POI but are accompanied by a simultaneous reduction in opioid use. Pharmacologic means of stimulating gut motility have not shown a positive effect, and the routine use of nasogastric tubes only increases morbidity. Recent multi-site phase III trials with alvimopan, a peripherally acting mu-antagonist, have shown significant reductions in POI and LOS by 12 and 16 hours, respectively, by blunting the effects of narcotics on gut motility while sparing centrally mediated analgesia. Use of alvimopan, along with a multi-modal postoperative treatment plan involving early ambulation, feeding, and avoiding nasogastric tubes, will likely be the crux of POI treatment and prevention.

Treatment of postoperative ileus with choline citrate--results of a prospective, randomised, placebo-controlled, double-blind multicentre trial

OBJECTIVES

This was a prospective, randomised, placebo-controlled, double-blind multicentre trial to analyse the efficacy of choline citrate in patients with postoperative ileus (POI) after elective colorectal surgery.

METHODS

From October 2005 until June 2008, 122 patients with POI were randomised to receive choline citrate or placebo. One hundred twenty patients were evaluable for tolerability and 107 patients were evaluable for efficacy. The treatment group, 47% (50/107), received 300.2 mg choline citrate intravenously, while the placebo group, 53% (57/107), received sodium chloride. Injections were performed every 12 h until defecation.

RESULTS

Demographic data analysis did not show clinically differences between both groups. Operative procedures included 40% (43/107) hemicolectomy, 38% (41/107) sigmoid resection and 22% (23/107) other colorectal resections. Defecation occurred after an average of 91.8 ± 26.6 h postoperatively in the treatment group, vs. 96.7 ± 35.2 h in the placebo group (p = 0.805). After laparoscopy, defecation occurred after 78.7 ± 25.3 h, vs. 99.2 ± 31.6 h after laparotomy (p = 0.001). Serious adverse effects occurred in 2% (1/60) in the treatment group, vs. 3% (2/60) in the placebo group. None of the events have been assessed as related to the study medication.

CONCLUSION

An efficacy of choline citrate in the treatment of POI after elective colorectal surgery could not be verified. The problem of POI requiring drug treatment seems to be less frequent than suggested by the literature. With technical advances in surgery, especially laparoscopic and fast track surgery, the frequency of POI will further decrease in the future.

Anesthetic Routines: The Anesthesiologist's Role in GI Recovery and Postoperative Ileus

All patients undergoing bowel resection experience postoperative ileus, a transient cessation of bowel motility that prevents effective transit of intestinal contents or tolerance of oral intake, to varying degrees. An anesthesiologist plays a critical role, not only in the initiation of surgical anesthesia, but also with the selection and transition to effective postoperative analgesia regimens. Attempts to reduce the duration of postoperative ileus have prompted the study of various preoperative, perioperative, and postoperative regimens to facilitate gastrointestinal recovery. These include modifiable variables such as epidural anesthesia and analgesia, opioid-sparing anesthesia and analgesia, fluid restriction, colloid versus crystalloid combinations, prokinetic drugs, and use of the new peripherally acting mu-opioid receptor (PAM-OR) antagonists. Review and appropriate adaptation of these multiple modifiable interventions by anesthesiologists and their surgical colleagues will facilitate implementation of a best-practice management routine for bowel resection procedures that will benefit the patient and the healthcare system.

Nutritional strategies in severe acute pancreatitis: a systematic review of the evidence

Nutrition in severe acute pancreatitis is a critical aspect in the management of this condition. This review aims to systematically review the evidence available to inform the use of nutritional support in severe acute pancreatitis. High quality (level 1) evidence supports naso-jejunal enteral nutrition (NJ-EN) over parenteral nutrition (PN) reducing infectious morbidity and showing a trend towards reduced organ failure although there is no detectable difference in mortality. Trial data may underestimate benefit as patients are often recruited with predicted rather than proven severe disease. NJ-EN is safe when started immediately (level 3 evidence). NJ-EN is often impractical and naso-gastric (NG) feeding seems to be equivalent in terms of safety and outcomes whilst being more practical (level 2 evidence). Regarding feed supplementation, probiotic feed supplementation is not beneficial (level 1 evidence) the and may cause harm with excess mortality (level 2 evidence). No evidence exists to confirm benefit of the addition of prokinetics in severe acute pancreatitis (SAP) although their use is proven in other critically ill patients. Level 2 evidence does not currently support the use of combination immuno-nutrition though further work on individual agents may provide differing results. Level 2 evidence does not support intravenous supplementation of anti-oxidants and has demonstrated that these too may cause harm.

The role of mast cell stabilization in treatment of postoperative ileus: a pilot study

OBJECTIVES

Although postoperative ileus (POI) is considered multifactorial, intestinal inflammation resulting from manipulation-induced mast cell activation is recognized as an important pathophysiological mechanism. Therefore, mast cell stabilization may represent a new therapeutic approach to shortening POI. The aim of this paper was to study the effect of ketotifen, a mast cell stabilizer, on postoperative gastrointestinal transit in patients who underwent abdominal surgery.

METHODS

In this pilot study, 60 patients undergoing major abdominal surgery for gynecological malignancy with standardized anesthesia were randomized to treatment with ketotifen (4 or 12 mg) or placebo. Patients were treated for 6 days, starting 3 days before surgery. Gastric emptying of liquids, selected as a primary outcome parameter, was measured 24 h after surgery using scintigraphy. Secondary end points were (scintigraphically assessed) colonic transit, represented as geometrical center of activity (segment 1(cecum) to 7(stool)) and clinical parameters.

RESULTS

Gastric retention 1 h after liquid intake was significantly reduced by 12 mg (median 3% (1-7), P=0.01), but not by 4 mg ketotifen (18% (3-45), P=0.6) compared with placebo (16% (5-75)). Twenty-four hour colonic transit in placebo was 0.8 (0.0-1.1) vs. 1.2 (0.2-1.4) colon segments in the 12 mg ketotifen group (P=0.07). Abdominal cramps were significantly relieved in patients treated with 12 mg ketotifen, whereas other clinical parameters were not affected.

CONCLUSIONS

Ketotifen significantly improves gastric emptying after abdominal surgery and warrants further exploration of mast cell stabilizers as putative therapy for POI.

Pharmacologic Options to Prevent Postoperative Ileus

Objective:

To summarize the evidence on pharmacologic options in preventing postoperative ileus (POI).

Data Sources:

The Cochrane Database of Reviews and OVID databases and Food and Drug Administration (FDA) Web site were searched (1950–April 2009) using the term postoperative ileus.

Study Selection and Data Extraction:

Meta-analyses and randomized controlled trials were included for review. The FDA Web site was searched for clinical reviews and label information for drugs indicated for the prevention of POI.

Data Synthesis:

Three meta-analyses, 2 on gum-chewing and 1 on alvimopan, and 18 clinical trials were identified. Only gum chewing and alvimopan were effective in preventing POI. Gum chewing reduced the time to first flatus and bowel movement (weighted mean difference 21h, p = 0.0006 and 33h; p = 0.0002, respectively). In one meta-analysis, gum chewing significantly reduced length of stay (LOS) by 2.4 days (p < 0.00001) but this was not replicated in the second meta-analysis. Alvimopan shortened the time to reach a composite endpoint of solid food intake, plus/minus flatus, and bowel movement (93 vs 105 h; p < 0.001). A higher incidence of myocardial infarction was observed in a 12-month study of alvimopan for the treatment of opioid-induced bowel dysfunction, but not in studies in patients undergoing bowel resection. Alvimopan decreased the time to written hospital discharge order (hazard ratio 1.35; p<0.01), while the significance of a reduction in LOS (0.2–1.3 days) was not reported.

Conclusions:

Gum chewing and alvimopan are effective in preventing POI, but given safety concerns and higher cost with alvimopan, gum chewing may be preferred.

Erythromycin establishes early oral feeding in neonates operated for congenital intestinal atresias

PURPOSE

The recovery of gastrointestinal function following surgery for congenital intestinal atresias can be prolonged and may increase morbidity and hospital stay. This study was conducted to investigate the prokinetic effect of erythromycin in neonates undergoing surgery for small bowel atresias.

METHODS

A randomized-controlled trial was conducted at the Departments of Paediatrics and Paediatric Surgery, Military Hospital, Rawalpindi, Pakistan, from January to December 2007 to study the prokinetic effect of erythromycin (3 mg/kg per dose 4 times daily). Thirty consecutive neonates undergoing primary anastomosis for congenital small bowel atresias were randomly divided into two groups: group I (erythromycin) and group II (control). The groups were similar in terms of gestational age, sex, mode of delivery, birth weight and types of atresias. Postoperative recovery of intestinal functions was measured as time taken to achieve full enteral feed (150 ml/kg per 24 h), duration of total parenteral nutrition (TPN) and hospital stay.

RESULTS

Neonates receiving oral erythromycin achieved full enteral feeding early (13.07 vs. 16.13 days) required TPN for shorter duration (10.53 vs. 13.73 days) and their hospital stay was less (16.2 vs. 18.0 days) as compared to the neonates in the control group who did not receive any erythromycin. The differences were statistically significant.

CONCLUSION

The administration of oral erythromycin following primary anastomosis for small intestinal atresias results in early recovery of intestinal function, fewer days on TPN and a trend for shorter hospital stay.

Methylnaltrexone, a new peripherally acting mu-opioid receptor antagonist being evaluated for the treatment of postoperative ileus

Postoperative ileus (POI), a transient impairment of bowel function, is considered an inevitable response after open abdominal surgery. It leads to significant patient morbidity and increased hospital costs and length of stay. The pathophysiology is multifactorial, involving neurogenic, hormonal, inflammatory and pharmacologic mediators. Several treatments have been shown to reduce the duration of POI, and a multimodal approach combining several of these interventions seems to be the most effective treatment option. Various drug therapies have been evaluated for the treatment of POI, although most have not shown any benefit. Peripherally active mu-opioid receptor antagonists are a new class of compounds that selectively block the peripheral (i.e., gastrointestinal [GI]) effects of opioids while preserving centrally mediated analgesia. Recently, alvimopan was approved in the US for the treatment of POI after abdominal surgery with bowel resection. Methylnaltrexone is a peripherally active mu-opioid receptor antagonist that has been shown to antagonize the inhibitory effects of opioids on GI transit without impairing analgesia. Phase II data indicated that methylnaltrexone was effective for improving GI recovery, reducing POI and shortening the time to discharge readiness in patients who underwent segmental colectomy. Two Phase III trials have been completed, and one is underway at present. Preliminary results from the two completed trials indicate that methylnaltrexone was not better than placebo for the primary or secondary outcomes. Further analyses of these data, clinical trial designs and the various dosage forms are necessary to determine the potential role of methylnaltrexone in the treatment of POI.

Effect of bisacodyl on postoperative bowel motility in elective colorectal surgery: a prospective, randomized trial

BACKGROUND

Postoperative ileus is a common condition after abdominal surgery. Many prokinetic drugs have been evaluated including osmotic laxatives. The data on colon-stimulating laxatives are scarce. This prospective, randomized, double-blind trial investigates the effect of the colon-stimulating laxative bisacodyl on postoperative ileus in elective colorectal resections.

MATERIALS AND METHODS

Between November 2004 and February 2007, 200 consecutive patients were randomly assigned to receive either bisacodyl or placebo. Primary endpoint was time to gastrointestinal recovery (mean time to first flatus passed, first defecation, and first solid food tolerated; GI-3). Secondary endpoints were incidence and duration of nasogastric tube reinsertion, incidence of vomiting, length of hospital stay, and visual analogue scores for pain, cramps, and nausea.

RESULTS

One hundred sixty-nine patients were analyzed, and 31 patients discontinued the study. Groups were comparable in baseline demographics. Time to GI-3 was significantly shorter in the bisacodyl group (3.0 versus 3.7 days, P = 0.007). Of the single parameters defining GI-3, there was a 1-day difference in time to defecation in favor to the bisacodyl group (3.0 versus 4.0 days, P = 0.001), whereas no significant difference in time to first flatus or tolerance of solid food was seen. No significant difference in the secondary endpoints was seen. Morbidity and mortality did not differ between groups.

CONCLUSION

Bisacodyl accelerated gastrointestinal recovery and might be considered as part of multimodal recovery programs after colorectal surgery.

Adynamic ileus and acute colonic pseudo-obstruction

Ileus and colonic pseudo-obstruction cause functional obstruction of intestinal transit, without mechanical obstruction, because of uncoordinated or attenuated intestinal muscle contractions. Ileus usually arises from an exaggerated intestinal reaction to abdominal surgery that is often exacerbated by numerous other conditions. Colonic pseudo-obstruction is induced by numerous metabolic disorders, drugs that inhibit intestinal motility, severe illnesses, and extensive surgery. It presents with massive colonic dilatation with variable, moderate small bowel dilatation. Both conditions are initially treated with supportive measures that include intravenous rehydration, correction of electrolyte abnormalities, discontinuation of antikinetic drugs, and treatment of other contributing disorders. Specific therapies for colonic pseudo-obstruction include neostigmine (an anticholinesterase) for pharmacologic colonic decompression and colonoscopic decompression.

MRI scoring system including dynamic motility evaluation in assessing the activity of Crohn's disease of the terminal ileum

RATIONALE AND OBJECTIVES

We sought to investigate the value of a MRI scoring system including dynamic motility evaluation in the assessment of small bowel Crohn's disease activity.

MATERIALS AND METHODS

From March 2005 to December 2006, 52 patients with suspected Crohn's disease onset or relapse underwent MRI on a 1.5-T magnet. Bowel distention was achieved orally assuming a mean of 1.6 L of a polyethyleneglycol (PEG) preparation. Per-patient assessment of disease activity was based on a scoring system including evaluation of morphology and motility of the small bowel and perivisceral structures (true-FISP, cine-true-FISP, and HASTE T2W sequences) and dynamic assessment of parietal contrast enhancement (FLASH T1W sequence). Patients were included in three categories, using endoscopic biopsy as the standard reference: no activity/quiescent disease, mild activity, or moderate-to-severe activity. Patients without terminal ileum involvement were excluded from data analysis.

RESULTS

MRI allowed a detailed and panoramic evaluation of the small bowel in all subjects examined. MRI properly assessed 14 of 16 (87.5%) cases of no activity/quiescent disease, 12 of 14 (85.7%) cases of mild activity, and 15 of 15 (100%) cases of severe activity. Overall, activity score led to a per-patient misdiagnosis of disease activity in a nonsignificant proportion of subjects (4 of 45; 8.8%) (P > .05), determining two false-positive and two false-negative results of mild disease activity. Sensitivity, specificity, PPV, NPV, and overall accuracy in assessing disease activity were 93.1%, 87.5%, 93.1%, 87.5%, and 91.1%, respectively.

CONCLUSION

Accurate assessment of Crohn's disease activity is achieved by using an activity score providing an overall interpretation of MRI findings.

New therapies in the treatment of postoperative ileus after gastrointestinal surgery

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.

Systemic prokinetic pharmacologic treatment for postoperative adynamic ileus following abdominal surgery in adults

BACKGROUND

Postoperative adynamic bowel atony interferes with recovery following abdominal surgery. Prokinetic pharmacologic drugs are widely used to accelerate postoperative recovery.

OBJECTIVES

To evaluate the benefits and harms of systemic acting prokinetic drugs to treat postoperative adynamic ileus in patients undergoing abdominal surgery.

SEARCH STRATEGY

Trials were identified by computerised searches of the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and the Cochrane Colorectal Cancer Group specialised register. The reference lists of included trials and review articles were tracked and authors contacted.

SELECTION CRITERIA

Randomised controlled parallel-group trials (RCT) comparing the effect of systemically acting prokinetic drugs against placebo or no intervention.

DATA COLLECTION AND ANALYSIS

Four reviewers independently extracted the data and assessed trial quality. Trial authors were contacted for additional information if needed.

MAIN RESULTS

Thirty-nine RCTs met the inclusion criteria contributing a total of 4615 participants. Most trials enrolled a small number of patients and showed moderate to poor (reporting of) methodological quality, in particular regarding allocation concealment and intention-to-treat analysis. Fifteen systemic acting prokinetic drugs were investigated and ten comparisons could be summarized. Six RCTs support the effect of Alvimopan, a novel peripheral mu receptor antagonist. However, the trials do not meet reporting guidelines and the drug is still in an investigational stage. Erythromycin showed homogenous and consistent absence of effect across all included trials and outcomes. The evidence is insufficient to recommend the use of cholecystokinin-like drugs, cisapride, dopamine-antagonists, propranolol or vasopressin. Effects are either inconsistent across outcomes, or trials are too small and often of poor methodological quality. Cisapride has been withdrawn from the market due to adverse cardiac events in many countries. Intravenous lidocaine and neostigmine might show a potential effect, but more evidence on clinically relevant outcomes is needed. Heterogeneity among included trials was seen in 10 comparisons. No major adverse drug effects were evident.

AUTHORS' CONCLUSIONS

Alvimopan may prove to be beneficial but proper judgement needs adherence to reporting standards. Further trials are needed on intravenous lidocaine and neostigmine. The remaining drugs can not be recommended due to lack of evidence or absence of effect.

Use of chewing gum in reducing postoperative ileus after elective colorectal resection: a systematic review

PURPOSE

Published studies comparing the addition of chewing gum to standardized postoperative care to shorten postoperative ileus showed controversial results. This study was designed to conduct a systematic review of all relevant trials on chewing gum to reduce postoperative ileus after colorectal resection.

METHODS

All published trials that compared the additional use of gum chewing with standard postoperative management were identified from Ovid MEDLINE, EMBASE, CINAHL, and All Evidence-Based Medicine Reviews between January 1991 and January 2007. The clinical outcomes were extracted and meta-analysis was performed by Forest plot review.

RESULTS

Five randomized, controlled trials with 158 (94 males) patients with mean age of 61.9 years were included. Seventy-eight patients received an addition of gum chewing and 80 had standard postoperative care for colorectal resection. Operating time (P = 0.78) and blood loss (P = 0.48) were similar. All patients tolerated the gum without any side-effects. With combined standard postoperative care and gum chewing, the patients passed flatus 24.3 percent earlier (weighted mean difference, -20.8 hours; P = 0.0006) and had bowel movement 32.7 percent earlier (weighted mean difference, -33.3 hours; P = 0.0002). They were discharged 17.6 percent earlier than those having ordinary postoperative treatment (weighted mean difference, -2.4 days; P < 0.00001). The gum-chewing group was associated with similar overall postoperative complication rate (odds ratio, 0.45; P = 0.05) with individual complication showing a trend favoring gum chewing, although they were not of statistical significance. Readmission (odds ratio, 0.36; P = 0.24) and reoperation rates (odds ratio, 1.36; P = 0.83) of the two groups were similar.

CONCLUSIONS

The use of gum chewing in the postoperative period is a safe method to stimulate bowel motility and reduce ileus after colorectal surgery.

Standardized concept for the treatment of gastrointestinal dysmotility in critically ill patients--current status and future options

Inhibition of gastrointestinal motility is a major problem in critically ill patients. Motor stasis gives rise to subsequent complications including intolerance to enteral feeding, enhanced permeability of the atrophic intestinal mucosa and conditions as severe as systemic inflammatory response syndrome, sepsis and multiple organ failure. Although the diagnosis of motility disturbances in critically ill patients is difficult, the type and site of the disturbance are important to consider in the analysis of the condition and in the choice of therapeutic approach. The pharmacological treatment of impaired gastrointestinal motility is difficult to handle for the clinician, because the underlying mechanisms are complex and not fully understood and the availability of pharmacological treatment options is limited. In addition, there is a lack of controlled studies on which to build an evidence-based treatment concept for critically ill patients. Notwithstanding this situation, there has been remarkable progress in the understanding of the integrated regulation of gastrointestinal motility in health and disease. These advances, which largely relate to the organization of the enteric nervous system and its signaling mechanisms, enable the intensivist to develop a standardized concept for the use of prokinetic agents in the treatment of impaired gastrointestinal motility in critically ill patients.

Treatment of Postoperative Ileus After Bowel Surgery with Low-Dose Intravenous Erythromycin

OBJECTIVES

Treatment of postoperative ileus remains unsatisfactory. Erythromycin (EM), a macrolide antibiotic, has prokinetic effects on the gut. We investigated whether intravenous erythromycin decreases the time to the return of normal bowel function after bowel surgery in patients with bladder cancer and interstitial cystitis who have undergone cystectomy and urinary diversion.

METHODS

We conducted a double-blind, randomized, placebo-controlled study of 22 volunteers. On the first postoperative day, patients began receiving intravenous erythromycin (125 mg) or placebo every 8 hours (maximum of 21 doses). The patients' ability to tolerate a general diet and return of bowel function was monitored.

RESULTS

A general diet was tolerated at a median of 9 days postoperatively for the EM arm and 8 for the placebo arm (P = 0.60). The first bowel sounds were detected at an average of 2 postoperative days for the EM arm and 3 for the placebo arm (P = 0.88). First flatus was present an average of 5 days postoperatively for both study arms (P = 0.35). The first bowel movement was present an average of 6 days postoperatively for the EM arm and 5 for the placebo arm (P = 0.98).

CONCLUSIONS

No significant difference was found between EM and placebo with regard to the onset of bowel sounds, passage of flatus, passage of the first bowel movement, and the time to tolerate a general diet. These data indicate that erythromycin is not useful in improving postoperative bowel function.

Review of the pathophysiology and management of postoperative ileus

Investigations in the pathophysiology and treatment of postoperative ileus continue to evolve. Bowel rest is no longer a mandatory component of postoperative recovery. Tolerance of enteral nutrition and normalization of the abdominal examination are more accurate indications of the resolution of postoperative ileus than passage of flatus or first bowel movement. A multimodal "fast track" recovery approach incorporated into a clinical pathway provides a more rapid return of intestinal function and shortened hospital stay in patients undergoing major, uncomplicated gastrointestinal surgery.

Postoperativer Ileus

Continuous improvements in surgical technique and anaesthesia for ileus have resulted in a significant reduction of perioperative complications. Postoperative outcome of surgical patients is increasingly dependent on the severity of postoperative ileus, which often determines morbidity and length of hospital stay. In the present article we discuss possible variables influencing this disease. Furthermore, means of prevention and therapeutic strategies for postoperative ileus are briefly presented.

Does gum chewing reduce postoperative ileus following open colectomy for left-sided colon and rectal cancer? A prospective randomized controlled trial

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.