Postoperative Ileus-Related Morbidity Profile in Patients Treated with Alvimopan after Bowel Resection

Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons

The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.

Enhanced Recovery after Surgery Protocol Accelerates Recovery of Lumbar Disc Herniation among Elderly Patients Undergoing Discectomy via Promoting Gastrointestinal Function

This study aimed to analyze the effect of the enhanced recovery after surgery (ERAS) protocol on the recovery of gastrointestinal function in patients with lumbar disc herniation after discectomy. A total of 179 patients with lumbar disc herniation were randomly divided into the ERAS and non-ERAS groups. The non-ERAS group received routine nursing, and the ERAS group received ERAS strategy. The two groups were compared for general recovery indicators such as postoperative hemoglobin and prealbumin, satisfaction, and length of hospital stay. Gastrointestinal function was also evaluated, such as postoperative feeding time, intestinal chirping recovery time, intestinal exhaust gas recovery time, and complications such as ileus, nausea, and vomiting. The satisfaction of patients in the ERAS group (86.15 ± 2.43) was significantly higher than that in the non-ERAS group (77.19 ± 3.32), and the difference was statistically significant (P < 0.05). The average time of eating in the ERAS group was 2.27 h after surgery. In addition, the amount of eating in the ERAS group was significantly better than that in the non-ERAS group, and the difference was statistically significant. In the ERAS group, intestinal chirping recovery time recovered to normal time, and exhaust recovery time and average defecation time were significantly shorter than those in the non-ERAS group. In the ERAS group, the average amount of hemoglobin and prealbumin decreased 3 days after operation, which was significantly lower than that in the non-ERAS group. To sum up, ERAS has an evident effect on the recovery of gastrointestinal function after discectomy of disc herniation, which can promote the recovery of patients.

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update

BACKGROUND

This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery.

METHODS

A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly.

CONCLUSIONS

The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.

Impact of enhanced recovery after surgery (ERAS) protocol on gastrointestinal function in gynecologic oncology patients undergoing laparotomy

OBJECTIVE

To evaluate the impact of enhanced recovery after surgery (ERAS) on postoperative gastrointestinal function in gynecologic oncology patients.

METHODS

This retrospective cohort study compared gynecology oncology patients undergoing non-emergent laparotomy from 10/2016 to 6/2017 managed on an ERAS protocol to a control cohort from the year prior to ERAS implementation. Major changes to postoperative care after ERAS implementation included multimodal analgesia, early feeding, goal-directed fluid resuscitation, and early ambulation. The primary outcome was rate of postoperative ileus, defined as nausea and vomiting requiring nothing-per-mouth status or nasogastric tube (NGT) placement. Secondary outcomes included length of stay (LOS) and 30-day readmission.

RESULTS

376 patients met inclusion criteria; 197 in the control group and 179 in the ERAS group. Patient demographics were similar between groups. Ileus rate was significantly lower in the ERAS group (2.8% vs. 15.7%; p < 0.001), and fewer patients in the ERAS group required NGT placement (2.2% vs. 7.1%; p = 0.06). ERAS remained independently associated with decreased ileus rates when controlling for other patient and surgical factors (OR 0.2; p = 0.01). Epidural use was correlated with a significant increase in ileus risk (OR 2.6; p = 0.03), as was increased Charlson Comorbidity Index (OR 1.2; p < 0.01). LOS was significantly decreased in the ERAS group (2.9 vs. 4.0 days; p = 0.04), while 30-day readmission rates were similar (10.1% vs. 10.7%; p = 0.62).

CONCLUSIONS

Implementation of an ERAS protocol significantly decreases the risk of postoperative ileus in gynecologic oncology patients undergoing laparotomy. ERAS also reduced LOS compared to pre-ERAS controls.

Alvimopan in the setting of colorectal resection with an ostomy: To use or not to use?

BACKGROUND

Postoperative ileus (POI) is a major cause of morbidity, increased length of stay (LOS) and hospital cost after colorectal surgery. Alvimopan is a µ-opioid antagonist used to accelerate upper and lower gastrointestinal function after bowel resection. We hypothesized that alvimopan would reduce LOS in patients undergoing colorectal resection with stoma, a situation that has not been evaluated.

METHODS

A retrospective review (2010-2015) identified 58 patients who underwent colorectal resection for benign or malignant disease with stoma creation and received alvimopan. They were case-matched to 58 non-alvimopan patients based on age, BMI, baseline comorbidities, stoma type created and surgical approach. We compared overall LOS, incidence of POI and other postoperative complications.

RESULTS

There were equal numbers of laparoscopic (N = 18) and open resections (N = 40) in the alvimopan group and non-alvimopan group. There were also equal numbers of patients with an ileostomy (N = 37) or colostomy (N = 21) in each group. Overall, 41 patients underwent resection for malignant disease in the alvimopan group compared to 37 in the non-alvimopan group. There was a significant reduction in median LOS overall (alvimopan 5 (4-7) versus control 6 (4.75-9.25) days, P = 0.03). While the 6-day median LOS was similar for patients undergoing ileostomy creation (P = 0.25), alvimopan patients had a 3-day decreased median LOS that approached statistical significance (P = 0.06). The overall 30-day complication rate was higher in the control group (41.4 vs. 51.7%, P = 0.26), but the readmission rate within 30 days was higher in the alvimopan group (19 vs. 13.8%, P = 0.45). Neither of these differences reached statistically significance.

CONCLUSION

The use of alvimopan in patients undergoing colorectal resection with stoma is associated with a significantly shorter LOS, but the increased readmission rate warrants further study. Based on these data, alvimopan should be evaluated in a controlled setting for patients undergoing colorectal resection with colostomy creation.

Opioids and GI Motility-Friend or Foe?

OPINION STATEMENT

The use of opioids for the treatment of chronic non-cancer pain is growing at an alarming rate. Opioid-induced bowel dysfunction (OBD) is a common adverse effect of long-term opioid treatment manifesting as constipation, nausea, and vomiting. These effects are primarily mediated by peripheral μ-opioid receptors with resultant altered GI motility and function. As a result, patients may present with opioid-induced constipation (OIC), opioid-induced nausea and vomiting (OINV), and/or narcotic bowel syndrome (NBS). This often leads to decreased quality of life and in many cases, discontinuation of opioid therapy. There is limited evidence to support the use of traditional anti-emetics and laxatives in the treatment of OBD. Tapering the dose of opioids, switching to transdermal application, opioid rotation, or dual-action opioids, such as tapentadol, may be helpful in the treatment of OBD. Novel agents, such as peripherally acting μ-opioid receptor antagonists which target the cause of OIC, show promise in the treatment of OBD and should be considered when conventional laxatives fail. This chapter will review the pathophysiology of OBD, including OINV and OIC, and treatment options available.

Delayed gastrointestinal recovery after abdominal operation - role of alvimopan

Postoperative Ileus (POI), which occurs after surgical manipulation of the bowel during abdominal operations, is associated with prolonged hospital stay, increasing medical costs, and delayed advancement of enteral diet, which contributes to a significant economic burden on the healthcare system. The use of accelerated care pathways has shown to positively impact gut function, but inevitable postoperative opioid use contributes to POI. Alvimopan is a peripherally acting μ-opioid receptor antagonist designed to mitigate antimotility effects of opioids. In our review, we examined ten trials on alvimopan’s use after abdominal operations. Several of the earlier studies on patients undergoing bowel resection showed correlations between the study group and GI recovery as defined by passage of flatus, first bowel movement, and time to readiness for discharge. Data in patients undergoing total abdominal hysterectomy showed similarly decreased GI recovery time. Additionally, data within the past few years shows alvimopan is associated with more rapid GI recovery time in patients undergoing radical cystectomy. Based on our review, use of alvimopan remains a safe and potentially cost-effective means of reducing POI in patients following open GI surgery, radical cystectomy, and total abdominal hysterectomy, and should be employed following these abdominal operations.

Efficacy and safety of low-dose celecoxib in reducing post-operative paralytic ileus after major abdominal surgery

BACKGROUND

A number of interventions have been used to decrease the incidence of post-operative paralytic ileus. A secondary outcome of a randomized controlled study showed that COX-2 inhibitors decreased the incidence of paralytic ileus. We sought to study a large cohort of patients undergoing major abdominal operations who were treated with a COX-2 inhibitor.

METHODS

This is a retrospective review of prospectively collected data. All eligible patients were given a COX-2 inhibitor--celecoxib 100 mg--twice daily starting on the day of surgery until the seventh day post-operatively or discharge, whichever was earlier. The rate of paralytic ileus was calculated and compared with historical data. Secondary outcome measures were the effect of using COX-2 inhibitors on renal function, electrolytes and haemoglobin, morbidity and leak rates.

RESULTS

Two hundred and fifty-two patients were treated with celecoxib; the control arm consisted of 67 historical patients. Of the 252 patients, we had complete data for 235 patients and ileus in 17 patients (7.23%) compared with 13.4% in the control group (P = 0.05). Subgroup analysis showed ileus in 5.45% of colectomy patients and 6.36% of patients who have had a colectomy and high anterior resection. There was no detriment of measured blood tests. There were leaks in two treated patients, both of whom did not require a laparotomy.

CONCLUSIONS

The use of low-dose COX-2 inhibitor over a short period of time decreases the paralytic ileus rates and does not cause any significant morbidity.

Opioid induced nausea and vomiting

Opioids are broad spectrum analgesics that are an integral part of the therapeutic armamentarium to combat pain in the palliative care population. Unfortunately, among the adverse effects of opioids that may be experienced along with analgesia is nausea, vomiting, and/or retching. Although it is conceivable that in the future, using combination agents (opioids combined with agents which may nullify emetic effects), currently nausea/vomiting remains a significant issue for certain patients. However, there exists potential current strategies that may be useful in efforts to diminish the frequency and/or intensity of opioid-induced nausea/vomiting (OINV).

Randomized placebo-controlled study of intravenous methylnaltrexone in postoperative ileus

OBJECTIVE

This phase 2 study evaluated the safety and activity of intravenous methylnaltrexone on the duration of postoperative ileus in patients undergoing segmental colectomy.

METHODS

Adults (aged 18 years or older) with American Society of Anesthesiologists physical status of I, II, or III who underwent segmental colectomy, including partial colectomy, sigmoidectomy, cecectomy, or anterior proctosigmoidectomy, via laparotomy with general anesthesia, received intravenous methylnaltrexone 0.30 mg/kg or placebo every 6 h beginning within 90 min after end of surgery. Treatment continued until 24 h after the patient tolerated solid foods, was discharged, or for 7 d maximum. Efficacy endpoints included measures of gastrointestinal recovery and time to discharge eligibility.

RESULTS

A total of 65 patients (methylnaltrexone, n = 33; placebo, n = 32) were randomized. Mean time to first bowel movement was accelerated by 20 h (p = 0.038) and time to discharge eligibility was accelerated by 33 h (p = 0.049) with methylnaltrexone vs placebo. Opioid use was similar between groups until postoperative day 4, then fluctuated in the placebo group. Methylnaltrexone was generally well tolerated.

CONCLUSIONS

In this study, intravenous methylnaltrexone significantly decreased time to postoperative bowel recovery and eligibility for hospital discharge by ∼1 d, with an adverse event profile similar to placebo. These were two of several exploratory endpoints; not all efficacy endpoints showed a significant difference between methylnaltrexone and placebo. The efficacy results in this trial were not seen in two subsequent large-scale studies.

Cytokine levels in abdominal exudate predict prolonged postoperative ileus following surgery for colorectal carcinoma

The aim of the present study was to investigate whether the measurement of cytokines from abdominal exudate is valuable for the early diagnosis of prolonged postoperative ileus (PPOI) following colorectal surgery. In the present study, 100 consecutive patients who were scheduled to undergo elective resection for carcinoma of the sigmoid or rectum were investigated. Abdominal exudate was obtained via a drain tube following surgery for the detection of interleukin (IL)-1β, IL-6 and tumour necrosis factor (TNF)-α. The correlation among the cytokine levels on postoperative days 1, 3 and 5 and the development of PPOI was investigated. Eight patients developed PPOI which was diagnosed 10–15 days postoperatively. No significant differences were observed among the peritoneal cytokine levels on postoperative days 1 and 3 in the 8 patients who developed PPOI when compared with those of the 92 patients that did not develop PPOI. By contrast, cytokine levels on postoperative day 5 were significantly higher in patients who developed PPOI when compared with those of patients that did not develop PPOI. The cytokine levels significantly increased during the first 5 days postoperatively in patients who developed PPOI and significantly decreased in patients who did not develop PPOI. The results of the present study showed that the increase in peritoneal IL-1β, IL-6 and TNF-α levels may be an additional early diagnostic predictor of PPOI following colorectal surgery.

Procalcitonin in abdominal exudate to predict prolonged postoperative ileus following colorectal carcinoma surgery

BACKGROUND

Prolonged postoperative ileus (PPOI) is a common problem after major abdominal surgery and can cause postoperative morbidity, extended hospitalization, as well as increased health care costs.

AIM

To investigate whether the levels of cytokines from abdominal exudate are predictive for early diagnosis of PPOI after colorectal surgery.

METHODS

One hundred patients who had undergone elective resection for carcinoma of the sigmoid or rectum were recruited. The abdominal exudate was obtained from a drain tube after surgery to examine the levels of C-reactive protein (CRP), procalcitonin (PCT), and tumor necrosis factor alpha (TNF-α). The relationship between cytokine levels on postoperative day 1, 3 and 5 and the occurrence of PPOI was analyzed.

RESULTS

Eight patients developed PPOI, which was diagnosed on postoperative day 10-15. PCT levels on postoperative day 1 and 3 were not significantly different between the 8 patients who developed PPOI and the 92 patients without PPOI. In contrast, PCT levels on day 5 were significantly higher in patients who developed PPOI than in patients without PPOI. The levels of CRP and TNF-α were irregular from day 1 to 5, and were not significantly different.

CONCLUSIONS

Increased PCT levels in abdominal exudate may predict PPOI in the early period following colorectal surgery.

Postoperative ileus in colorectal surgery: is there any difference between laparoscopic and open surgery?

Background: Postoperative ileus is a major complication of patients undergoing abdominal surgery. The purpose of this study was to determine the effects of operative time and the method of surgery on postoperative ileus.

Methods: After institutional review board approval, 121 patients were studied in two groups. Group 1 consisted of 86 patients with colorectal cancers and Group 2 included 35 patients with diverticulitis. Various surgical procedures were performed in both groups. In all patients, the nasogastric (NG) tube was removed after termination of surgery. Clear liquids were offered commencing on the first postoperative day, followed by a regular diet as tolerated. GI-1 was the postoperative time to toleration of clear liquids, whereas GI-2 was the postoperative time to first bowel movement or flatus and toleration of a regular diet. Statistical analysis was performed using a linear regression model by disease with the first bowel movement or flatus as the dependent variable and operative time and category as explanatory variables.

Results: Vomiting after oral feeding occurred in 18 (20.9%) patients with cancer and in 7 (20.0%) patients with diverticular disease. An NG tube was reinserted in 13 (15.1%) patients in the cancer group and in 3 (8.6%) patients in the diverticular disease group. In patients with cancer, the duration of operation was associated with GI-2 (P = 0.011), whereas in patients with diverticulitis, the duration of operation was associated with GI-1 (P = 0.001) and GI-2 (P = 0.044). In the diverticulitis group, a significant relationship was found between GI-2 and operative category (P = 0.03).

Conclusion: Longer operations led to more prolonged postoperative ileus after both laparoscopy and laparotomy, regardless of malignant or benign pathology. In anticipation of and/or following longer operations, surgeons should consider measures to shorten postoperative ileus.

Alvimopan addition to a standard perioperative recovery pathway

BACKGROUND AND OBJECTIVES

Alvimopan, a peripherally acting mu-opioid receptor antagonist, decreased time to gastrointestinal recovery and hospital length of stay in open bowel resection patients in Phase 3 trials. However, the benefit in laparoscopic colectomy patients remains unclear.

METHODS

A retrospective case series review was performed to study addition of alvimopan to a well-established standard perioperative recovery pathway for elective laparoscopic colectomy. The main outcome measures were length of stay and incidence of charted postoperative ileus. Wilcoxon and chi-square tests were used to calculate P values for length of stay and postoperative ileus endpoints, respectively.

RESULTS

Demographic/baseline characteristics from the 101 alvimopan and 64 pre-alvimopan control patients were generally comparable. Mean length of stay in the alvimopan group was 1.55 days shorter (alvimopan, 2.81±0.95 days; control, 4.36±2.4 days; P<.0001). The proportion of patients with postoperative ileus was lower in the alvimopan group (alvimopan, 2%; control, 20%; P<.0001).

CONCLUSION

In this case series, addition of alvimopan to a standard perioperative recovery pathway decreased length of stay and incidence of postoperative ileus for elective uncomplicated laparoscopic colectomy. The improvement in the mean length of stay for patients who receive alvimopan is a step forward in achieving a fasttrack surgery model for elective laparoscopic colectomies.

A meta-analysis of the effectiveness of the opioid receptor antagonist alvimopan in reducing hospital length of stay and time to GI recovery in patients enrolled in a standardized accelerated recovery program after abdominal surgery

BACKGROUND

Despite accelerated recovery programs and the widespread uptake of laparoscopic surgery, postoperative ileus remains a significant factor affecting length of stay after abdominal surgery. Alvimopan, an opioid-receptor antagonist, may reduce the incidence of postoperative ileus and expedite hospital discharge.

OBJECTIVE

The aim of this study was to perform a meta-analysis to determine the role of alvimopan in accelerating GI recovery and hospital discharge after laparoscopic and open abdominal surgery performed within an accelerated recovery program.

DATA SOURCES AND STUDY SELECTION

Cochrane (1999-2010), Embase (1980-2010), MEDLINE (1980-2010), and International Pharmaceutical Abstracts (1970-2010) were searched for relevant double-blinded, randomized controlled trials.

INTERVENTIONS

Twelve milligrams of alvimopan and placebo were given to patients enrolled in an accelerated recovery program after abdominal surgery.

MAIN OUTCOME MEASURES

The primary outcomes measured were the length of stay as defined by the writing of the hospital discharge order and GI-3 and GI-2 GI tract recovery.

RESULTS

: Three trials were included that reported on a pooled modified intention-to-treat population of 1388 patients; 685 (49%) patients received alvimopan. On meta-analysis, alvimopan reduced time to the hospital discharge order (HR 1.37 (1.21, 1.62), p < 0.0001), GI-3 recovery (HR 1.42 (1.25, 1.62), p < 0.001), and GI-2 recovery (HR 1.49 (1.32, 1.68), p < 0.0001).

LIMITATIONS

The search criteria identified only a small number of trials of alvimopan after abdominal surgery with no randomized trials of alvimopan after laparoscopic surgery. In addition, the use of length of hospital stay as the primary outcome measure may be inappropriate, because it is open to many confounding factors. Finally, adverse events, in particular, adverse cardiovascular events, were not considered.

CONCLUSIONS

Alvimopan 12 mg can further reduce time to GI recovery and hospital discharge in patients undergoing abdominal surgery within an accelerated recovery program. Investigation into the effect of alvimopan following laparoscopic surgery and additional cost-benefit analyses are required to further define the role of this intervention.

Economic analysis of alvimopan for prevention and management of postoperative ileus

STUDY OBJECTIVE

To determine whether alvimopan for prevention of postoperative ileus in patients undergoing small- or large-bowel resection by laparotomy is associated with lower total costs compared with standard care.

DESIGN

Pharmacoeconomic analysis using a formal decision model.

DATA SOURCE

Four phase III clinical trials, two pooled analyses, and one meta-analysis.

PATIENT POPULATION

A cohort of patients who underwent bowel resection with primary anastomosis by laparotomy and received either standardized, accelerated postoperative care (usual care) or usual care plus alvimopan.

MEASUREMENTS AND MAIN RESULTS

Clinical outcomes, obtained from pooled analyses of published studies, were time to discharge order written, postoperative nasogastric tube insertion, postoperative ileus-related readmission within 7 days, and occurrence of nausea and vomiting. Cost inputs included drugs, nursing labor, readmissions, and hospitalizations. Costs were assessed by determining the net cost of alvimopan use and subsequent reduction in length of stay. Sensitivity and scenario analyses were conducted. Costs for alvimopan were $570 based on an average of 9.5 doses. Given the 18.4-hour mean reduction in time to discharge order written, use of alvimopan reduced hospitalization costs by $2021. Mean difference in overall cost of care, as determined by Monte Carlo simulation, was $1168 (95% certainty interval -$437 to $5879), favoring the use of alvimopan. In the sensitivity analysis, association of alvimopan with lower costs was robust to several changes in key parameters including cost and number of doses of alvimopan, time to discharge order written, readmission rates, and hospitalization cost. In the scenario analyses, alvimopan use yielded a net cost of $226 when no difference in time to discharge order written was assumed. In the scenario analysis using data from a study that did not enforce opioid use, alvimopan resulted in a cost saving of $65/patient.

CONCLUSION

Alvimopan was cost saving for prevention of postoperative ileus in patients undergoing bowel resection by laparotomy, although these potential cost savings were highly dependent on a difference in time to discharge order written. This finding is not applicable to the less-invasive laparoscopic surgical approach for which quality data on alvimopan use are lacking. Limitations of this analysis included use of time to discharge order written as a proxy for length of stay and difficulty interpreting study results due to inconsistent reporting and conduct of the clinical trials evaluating alvimopan. More research is needed to determine the cost-effectiveness of alvimopan.

Analgesic effects of melatonin: a review of current evidence from experimental and clinical studies

Melatonin is an endogenous indoleamine, produced mainly by the pineal gland. Melatonin has been proven to have chronobiotic, antioxidant, antihypertensive, anxiolytic and sedative properties. There are also experimental and clinical data supporting an analgesic role of melatonin. In experimental studies, melatonin shows potent analgesic effects in a dose-dependent manner. In clinical studies, melatonin has been shown to have analgesic benefits in patients with chronic pain (fibromyalgia, irritable bowel syndrome, migraine). The physiologic mechanism underlying the analgesic actions of melatonin has not been clarified. The effects may be linked to G(i) -coupled melatonin receptors, to G(i) -coupled opioid μ-receptors or GABA-B receptors with unknown downstream changes with a consequential reduction in anxiety and pain. Also, the repeated administration of melatonin improves sleep and thereby may reduce anxiety, which leads to lower levels of pain. In this paper, we review the current evidence regarding the analgesic properties of melatonin in animals and humans with chronic pain.

Influence of Intravenous Opioid Dose on Postoperative Ileus

Background:

Intravenous opioids represent a major component in the pathophysiology of postoperative ileus (POI). However, the most appropriate measure and threshold to quantify the association between opioid dose (eg, average daily, cumulative, maximum daily) and POI remains unknown.

Objective:

To evaluate the relationship between opioid dose, POI, and length of stay (LOS) and identify the opioid measure that was most strongly associated with POI,

Methods:

Consecutive patients admitted to a community teaching hospital who underwent elective colorectal surgery by any technique with an enhanced-recovery protocol postoperatively were retrospectively identified. Patients were excluded if they received epidural analgesia, developed a major intraabdominal complication or medical complication, or had a prolonged workup prior to surgery. Intravenous opioid doses were quantified and converted to hydromorphone equivalents. Classification and regression tree (CART) analysis was used to determine the dosing threshold for the opioid measure most associated with POI and define high versus low use of opioids. Risk factors for POI and prolonged LOS were determined through multivariate analysis.

Results:

The incidence of POI in 279 patients was 8.6%. CART analysis identified a maximum daily intravenous hydromorphone dose of 2 mg or more as the opioid measure most associated with POI. Multivariate analysis revealed maximum daily hydromorphone dose of 2 mg or more (p = 0.034), open surgical technique (p = 0.045), and days of intravenous narcotic therapy (p = 0.003) as significant risk factors for POI. Variables associated with increased LOS were POI (p < 0.001), maximum daily hydromorphone dose of 2 mg or more (p < 0.001), and age (p = 0.005); laparoscopy (p < 0.001) was associated with a decreased LOS.

Conclusions:

Intravenous opioid therapy is significantly associated with POI and prolonged LOS, particularly when the maximum hydromorphone dose per day exceeds 2 mg. Clinicians should consider alternative, nonopioid-based pain management options when this occurs.

The opioid component of delayed gastrointestinal recovery after bowel resection

INTRODUCTION

Patients undergoing bowel resection or other major abdominal surgery experience a period of delayed gastrointestinal recovery associated with increased postoperative morbidity and longer hospital length of stay. Symptoms include nausea, vomiting, abdominal distension, bloating, pain, intolerance to solid or liquid food, and inability to pass stool or gas. The exact cause of delayed gastrointestinal recovery is not known, but several factors appear to play a central role, namely the neurogenic, hormonal, and inflammatory responses to surgery and the response to exogenous opioid analgesics and endogenous opioids.

DISCUSSION

Stimulation of opioid receptors localized to neurons of the enteric nervous system inhibits coordinated gastrointestinal motility and fluid absorption, thereby contributing to delayed gastrointestinal recovery and its associated symptoms. Given the central role of opioid analgesics in delayed gastrointestinal recovery, a range of opioid-sparing techniques and pharmacologic agents, including opioid receptor antagonists, have been developed to facilitate faster restoration of gastrointestinal function after bowel resection when used as part of a multimodal accelerated care pathway. This review discusses the etiology of opioid-induced gastrointestinal dysfunction as well as clinical approaches that have been evaluated in controlled clinical trials to reduce the opioid component of delayed gastrointestinal recovery.

Novel opioid antagonists for opioid-induced bowel dysfunction

INTRODUCTION

Adverse effects frequently limit the therapeutic benefits of opioid analgesics. Gastrointestinal adverse effects are common, burdensome, and can compromise the quality of life. It is estimated that up to 81% of patients still report constipation despite regular use of laxatives. Thus, the development of opioid antagonists that selectively target receptors in the gut without affecting central analgesia has provided new perspectives on the treatment of opioid-induced gastrointestinal adverse effects.

AREAS COVERED

In this paper, we review the pathophysiology, prevalence, and burden of opioid-induced bowel dysfunction (OBD). In addition, this study aims to provide a better understanding of the mechanism of action and reviews the efficacy, safety and the latest research on novel opioid antagonists for OBD.

EXPERT OPINION

Two strategies effectively relieve OBD without interfering with centrally mediated analgesia: the administration of opioid antagonists with limited systemic absorption and peripherally acting mu-opioid receptor antagonists (PAMORA) that selectively target mu-receptors in the gastrointestinal tract. Methylnaltrexone and alvimopan are two recently marketed PAMORA and provide a new mechanism-based approach for the treatment of opioid-induced gastrointestinal dysfunction. However, its use in clinical practice is limited by various reasons such as its relatively low response rates and higher costs. Nevertheless, at least four new oral PAMORA (NKTR-118, TD-1211, ADL-7445, and ADL-5945) are under clinical development, further expanding the possibilities for a new paradigm for OBD management.

Resolution of opioid-induced postoperative ileus in a newborn infant after methylnaltrexone

Transient impairment of bowel function is a frequent and distressing problem in neonates on opioid-induced analgesia. Methylnaltrexone, a peripheral-acting μ-opioid receptor antagonist, has been studied in adults for the treatment of opioid-induced constipation in advanced illness and has been suggested as a promising therapeutic concept for reducing postoperative ileus. Here, we report on a newborn infant on fentanyl analgesia after major abdominal surgery with aggravated ileus. After 8 days of quiescent bowel, the patient's intestinal dysmotility resolved within 15 minutes after intravenous administration of methylnaltrexone (0.15 mg/kg body weight). Methylnatrexone was repeated daily until cessation of fentanyl administration. There were no signs of pain or opioid withdrawal.

An Evaluation of Alvimopan Use as Part of Perioperative Management of Patients Undergoing Laparoscopic Small and Large Bowel Resections

Objective

Delayed gastrointestinal (GI) recovery (postoperative ileus) is a risk for patients undergoing bowel resection (BR) and presents clinical challenges including prolonged hospital length of stay (LOS) and increased postoperative morbidity. Alvimopan, an oral, peripherally acting mu-opioid receptor antagonist, is the first therapy approved to accelerate GI recovery after BR. Published data have described alvimopan use in open BR. In contrast, this study focused on laparoscopic BR.

Methods

Historic data were retrospectively collected and alvimopan data were prospectively collected from 1 surgeon at our facility. Adults undergoing laparoscopic partial small or large BR with primary anastamosis scheduled to receive intravenous, opioid-based, patient-controlled analgesia were eligible. Pregnancy, opioid analgesic on the home medication reconciliation form, complete bowel obstruction, colostomy or ileostomy creation, and unplanned surgery were exclusion criteria. All patients were uniformly managed with a standardized accelerated postoperative care pathway to facilitate GI recovery. LOS, time to first bowel movement (BM), 30-day readmission rate, and the cost were evaluated. Data were analyzed using Pearson chi-square and independent samples t tests.

Results

Thirty-nine alvimopan and 56 historic cohort patients were included. Time to first BM was reduced by 1.2 days and LOS was reduced by 1.1 days (both P < .001) in the alvimopan cohort compared with control. Overall variable cost data were reduced by $1,368 in the alvimopan cohort. Readmission rates were low and comparable.

Conclusions

Laparoscopic surgery can decrease LOS compared with open BR; however, alvimopan use at our facility reduced LOS and time to BM while remaining cost-effective in this patient population.

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.

Alvimopan for the management of postoperative ileus after bowel resection: characterization of clinical benefit by pooled responder analysis

Background

A pooled post hoc responder analysis was performed to assess the clinical benefit of alvimopan, a peripherally acting mu-opioid receptor (PAM-OR) antagonist, for the management of postoperative ileus after bowel resection.

Methods

Adult patients who underwent laparotomy for bowel resection scheduled for opioid-based intravenous patient-controlled analgesia received oral alvimopan or placebo preoperatively and twice daily postoperatively until hospital discharge or for 7 postoperative days. The proportion of responders and numbers needed to treat (NNT) were examined on postoperative days (POD) 3–8 for GI-2 recovery (first bowel movement, toleration of solid food) and hospital discharge order (DCO) written.

Results

Alvimopan significantly increased the proportion of patients with GI-2 recovery and DCO written by each POD (P < 0.001 for all). More patients who received alvimopan achieved GI-2 recovery on or before POD 5 (alvimopan, 80%; placebo, 66%) and DCO written before POD 7 (alvimopan, 87%; placebo, 72%), with corresponding NNTs equal to 7.

Conclusions

On each POD analyzed, alvimopan significantly increased the proportion of patients who achieved GI-2 recovery and DCO written versus placebo and was associated with relatively low NNTs. The results of these analyses provide additional characterization and support for the overall clinical benefit of alvimopan in patients undergoing bowel resection.

Pathogenesis and management of postoperative ileus

Postoperative ileus (POI) is a predictable delay in gastrointestinal (GI) motility that occurs after abdominal surgery. Probable mechanisms include disruption of the sympathetic/parasympathetic pathways to the GI tract, inflammatory changes mediated over multiple pathways, and the use of opioids for the management of postoperative pain. Pharmacologic treatment of postoperative ileus continues to be problematic as most agents are unreliable and unsubstantiated with robust clinical trials. The selective opioid antagonist alvimopan has shown promise in reducing POI, but needs more rigorous investigation. Clinician interventions proven to be of benefit include laparoscopy, thoracic epidural anesthesia, avoidance of opioids, and early feeding. Early ambulation may also contribute to early resolution of POI; however, routine nasogastric decompression plays no role and may increase complications. Multimodal care plans remain the mainstay of treatment for POI.

Electro-acupuncture to prevent prolonged postoperative ileus: A randomized clinical trial

AIM: To examine whether acupuncture can prevent prolonged postoperative ileus (PPOI) after intraperitoneal surgery for colon cancer.

METHODS: Ninety patients were recruited from the Fudan University Cancer Hospital, Shanghai, China. After surgery, patients were randomized to receive acupuncture (once daily, starting on postoperative day 1, for up to six consecutive days) or usual care. PPOI was defined as an inability to pass flatus or have a bowel movement by 96 h after surgery. The main outcomes were time to first flatus, time to first bowel movement, and electrogastroenterography. Secondary outcomes were quality of life (QOL) measures, including pain, nausea, insomnia, abdominal distension/fullness, and sense of well-being.

RESULTS: No significant differences in PPOI on day 4 (P = 0.71) or QOL measures were found between the groups. There were also no group differences when the data were analyzed by examining those whose PPOI had resolved by day 5 (P = 0.69) or day 6 (P = 0.88). No adverse events related to acupuncture were reported.

CONCLUSION: Acupuncture did not prevent PPOI and was not useful for treating PPOI once it had developed in this population.

Postoperative ileus: it costs more than you expect

BACKGROUND

The clinical impact of postoperative ileus (POI) after colectomy is difficult to quantify financially because of administrative coding limitations. Accurate data are important to allow pharmaco-economic analysis of methods aimed at reducing POI. The aim of this study was to assess the financial impact of POI for the 30-day episode of care for colectomy.

STUDY DESIGN

We reviewed all colectomy patients at our institution from July 2007 to June 2008. Primary POI was defined as more than three episodes of emesis with return to NPO diet status and/or reinsertion of nasogastric tube; secondary POI was associated with intraabdominal complications. Readmission for gastrointestinal failure was defined as delayed POI (no radiologic or surgical identification of small bowel obstruction). All other complications requiring readmission were grouped together for analysis. Data reviewed included primary admission and readmission costs, reason for readmission, intervention, index and total length of stay, narcotic use, time to ambulation, and time to enteral feeds.

RESULTS

One hundred eighty-six colectomies were eligible for analysis, with 45 cases (38 primary and 7 secondary) of POI during the index admission. The total cost was significantly higher for patients with POI ($16,612 versus $8,316; p < 0.05). However, readmission costs were not statistically different for delayed POI and other complications ($3,546 versus $6,705).

CONCLUSIONS

POI occurred in 24% (84% primary) of colectomy patients and disproportionately affected cost at the index admission. Interestingly, delayed POI was similar in cost to readmission for other serious adverse surgical complications.

Clinical trial: the impact of cyclooxygenase inhibitors on gastrointestinal recovery after major surgery - a randomized double blind controlled trial of celecoxib or diclofenac vs. placebo

BACKGROUND

Ileus occurs after abdominal surgery and may be severe. Inhibition of prostaglandin release reduces post-operative ileus in a rat model.

AIM

To determine whether prostaglandin inhibition by cyclooxygenase inhibitors, celecoxib or diclofenac, could enhance gastrointestinal recovery and reduce post-operative ileus in humans.

METHODS

Two hundred and ten patients undergoing elective major abdominal surgery were randomized to receive twice daily placebo (n = 67), celecoxib (100 mg, n = 74) or diclofenac (50 mg, n = 69), preoperatively and continuing for up to 7 days. Primary outcomes were hallmarks of gut recovery. Secondary outcomes were paralytic ileus, pain and complications.

RESULTS

There was no clinically significant difference between the groups for restoration of bowel function. There was a significant reduction in paralytic ileus in the celecoxib-treated group (n = 1, 1%) compared with diclofenac (n = 7, 10%) and placebo (n = 9, 13%); P = 0.025, RR 0.20, CI 0.01-0.77. Pain scores, analgesia, transfusion requirements and adverse event rates were similar between study groups.

CONCLUSIONS

Perioperative low dose celecoxib, but not diclofenac, markedly reduced the development of paralytic ileus following major abdominal surgery, but did not accelerate early recovery of bowel function. This was independent of narcotic use and had no increase in post-operative complications.

Recent Advances in Pharmacotherapy

Many unique and clinically important medications were approved by the Food and Drug Administration from December 2007 through May 2008 for various conditions encountered in an internal medicine setting. These new treatments dramatically vary in their targeted body system and include agents for the cardiovascular system (nebivolol), central nervous system (desvenlafaxine), gastrointestinal tract (certolizumab, methylnaltrexone, and alvimopan), immunological function (etravirine), and metabolic function (sapropterin). This article discusses medications by their respective body system. Each review is comprised of an overview of the Food and Drug Administration–approved indication and the drug’s role in treatment of that disease state. Current dosing guidance, clinical efficacy and clinically relevant adverse drug reactions, drug interactions, contraindications, and precautions are also presented. This review is designed to focus on the new molecular entities and biological approvals clinicians may potentially encounter in an internal medicine practice.

Gastrointestinal recovery after laparoscopic colectomy: results of a prospective, observational, multicenter study

BACKGROUND

Although evidence suggests that laparoscopic colectomy (LC) results in faster gastrointestinal (GI) recovery than open bowel resection, previous studies were performed at single institutions or generally not controlled for diet introduction or perioperative care, making the results difficult to interpret. A prospective, observational, multicenter study was planned to investigate GI recovery, length of hospital stay (LOS), and postoperative ileus (POI)-related morbidity after LC.

METHODS

Patients scheduled to undergo LC or hand-assisted laparoscopic (HAL) bowel resection and to receive opioid-based postoperative intravenous patient-controlled analgesia were enrolled in 16 U.S. centers. The study design was similar to that for trials of alvimopan phase 3 open laparotomy bowel resection using a standardized accelerated postoperative care pathway. The primary end points were time to upper and lower GI recovery (GI-2: toleration of solid food and bowel movement) and postoperative LOS. The secondary end points included POI-related morbidity (postoperative nasogastric tube insertion or investigator-assessed POI resulting in prolonged hospital stay or readmission), conversion rate, and protocol-defined prolonged POI (GI-2 > 5 postoperative days).

RESULTS

In this study, 148 patients received hemicolectomy by the LC (42 left and 67 right) or HAL (39 left) approach. The conversion rate was 18.8% (25.4% LC left, 17.3% HAL left, 15% LC right). The mean time to GI-2 recovery was 4.4 days, and the mean postoperative LOS was 4.9 days, neither of which varied substantially by surgical approach. Prolonged POI occurred for 15 patients (10.1%), and POI-related morbidity occurred for 17 patients (11.5%). No patients were readmitted because of POI, whereas 3 patients (2%) were readmitted for all other causes.

CONCLUSIONS

Mean GI recovery and LOS after LC were accelerated compared with those for patients in open laparotomy bowel resection clinical trials or those reported in large hospital databases (0.7 and 1.7-2.2 days, respectively). Overall POI-related morbidity was similar between the open bowel resection and LC populations, demonstrating that POI continues to present with important morbidity regardless of the surgical approach.

The Clavien-Dindo classification of surgical complications: five-year experience

BACKGROUND AND AIMS

The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients', nurses', and doctors' perception.

MATERIAL AND METHODS

Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication.

RESULTS

We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test).

CONCLUSIONS

This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as "minor or major" should be removed from the surgical literature.

Peripherally acting mu-opioid receptor antagonists and postoperative ileus: mechanisms of action and clinical applicability

Postoperative ileus (POI), a transient cessation of coordinated bowel function after surgery, is an important health care problem. The etiology of POI is multifactorial and related to both the surgical and anesthetic pathways chosen. Opioids used to manage surgical pain can exacerbate POI, delaying gastrointestinal (GI) recovery. Peripherally acting mu-opioid receptor (PAM-OR) antagonists are designed to mitigate the deleterious effects of opioids on GI motility. This new class is investigational for POI management with the goal of accelerating the recovery of upper and lower GI tract function after bowel resection. In this review, we summarize the mechanisms by which POI occurs and the role of opioids and opioid receptors in the enteric nervous system, discuss the mechanism of action of PAM-OR antagonists, and review clinical pharmacology and Phase II/III POI trial results of methylnaltrexone and alvimopan. Finally, the role of anesthesiologists in managing POI in the context of a multimodal approach is discussed.

Safety and efficacy update: Alvimopan in postoperative ileus

Postoperative ileus (POI) in patients undergoing abdominal surgery is associated with significant morbidity. In 2008, alvimopan (Entereg®) was approved by the Food and Drug Administration (FDA), and is the only available POI therapy in the United States for patients undergoing bowel resection. Data from preclinical studies demonstrate that alvimopan and its primary metabolite, ADL 08-0011, behave as potent μ. opioid receptor antagonists. In animals, alvimopan and ADL 08-0011 attenuate opioid agonist-induced reductions in gastrointestinal (GI) transit. Higher doses of alvimopan are required to inhibit opioid-induced analgesia as a result of its inability to penetrate the central nervous system (CNS). ADL 08-0011 is also peripherally selective, although to a lesser degree than alvimopan. In multiple species, including humans, alvimopan has low oral bioavailability, while ADL 08-0011, following its generation by human gut microflora, is more readily absorbed and achieves higher exposures. Three Phase 2 and five Phase 3 clinical trials have been conducted to investigate the efficacy and tolerability of alvimopan in patients undergoing bowel resection. An additional Phase 3 study was conducted in hysterectomy patients. In the majority of the studies, statistically significant, and clinically meaningful, acceleration of GI recovery has been demonstrated. Consistent with animal data, alvimopan has no effect on opioid agonist-induced analgesia in healthy human subjects and POI patients. Clinical experience to date in POI patients indicates that alvimopan is well tolerated when used according to its approved dosing regimen (12 mg b.i.d. for up to 7 days). In this article, the preclinical and clinical properties of alvimopan are reviewed.

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.

Endogenous opiates and behavior: 2007

This paper is the thirtieth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2007 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.

Postoperative ileus--an update on preventive techniques

This article reviews techniques currently used to prevent or reduce the duration of postoperative ileus (POI), which is considered an undesirable stress response to major abdominal surgery that leads to discomfort, morbidity and prolonged hospital stay. In several randomized studies, a number of techniques have been demonstrated to reduce the occurrence and/or duration of POI: thoracic epidural analgesia with local anesthetics, peripheral opioid antagonists, laxatives, chewing gum, intravenous and incisional local anesthetics, and avoidance of routine nasogastric intubation and fluid excess. Early institution of oral feeding and laparoscopic surgery might also be effective, but there is less clear evidence available to support their use. When some of these techniques are combined as part of the concept of multimodal postoperative rehabilitation (fast-track surgery), the duration of POI after open or laparoscopic abdominal surgery can be reduced to 24-48 h in most patients. There is a need for data on the effect of these techniques on POI when applied to major upper abdominal surgeries and emergency abdominal operations (e.g. trauma, peritonitis, etc.).

Outcome of discharge within 24 to 72 hours after laparoscopic colorectal surgery

PURPOSE

Although laparoscopic colorectal surgery may permit early recovery and discharge from hospital, short lengths of stay are not routinely achieved. This is partly because accelerated recovery programs with early discharge are associated with high readmission and complication rates, especially after open colorectal surgery.

METHODS

This study was designed to examine safety and outcomes after laparoscopic colectomy in cases discharged within 72 hours of surgery. A total of 118 consecutive patients (mean age 60 years) underwent elective laparoscopic colectomy by a single surgeon. An accelerated recovery program included an overnight intravenous patient- controlled analgesia pump, diet and oral analgesia on postoperative Day 1, and standardized discharge criteria.

RESULTS

Mean body mass index was 28.5 (range, 20-45), and mean operative time was 142 minutes with no mortality. Median stay was 3 days, and 20 percent had a complication within 30 days. Eighty-two patients (70 percent) were discharged within 72 hours of surgery (10 Day 1; 46 Day 2; 26 Day 3). Patients were grouped and analyzed by day of discharge. Discharge on Days 1 to 2 was associated with significantly lower complication rates than seen for the overall group. Although patients discharged on Days 1 to 2 had the lowest readmission rate, this did not reach statistical significance.

CONCLUSIONS

Readmission and complication rates are low in patients discharged on Days 1, 2, or 3 after laparoscopic colectomy when using standardized postoperative care protocols and standardized discharge criteria.

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.

Alvimopan accelerates gastrointestinal recovery after bowel resection regardless of age, gender, race, or concomitant medication use

BACKGROUND

Postoperative ileus is a transient cessation of bowel motility that occurs after bowel resection (BR). Alvimopan, a peripherally acting mu-opioid receptor antagonist accelerated gastrointestinal (GI) recovery in 5 randomized, double-blind, phase III postoperative ileus trials.

METHODS

Individual covariates (age, gender, race) were assessed separately using Cox proportional hazards models that included the main effects of treatment and covariate factor. Time-to-GI recovery (GI-3 [first toleration of solid food and first bowel movement or flatus]; GI-2 [first toleration of solid food and first bowel movement]) for patients who underwent open laparotomy for BR in the absence of epidural anesthesia and received alvimopan (12 mg) or placebo was analyzed within subgroups (age, gender, race, concomitant medication use) using Cox proportional hazards models to generate hazard ratios (HRs). P values were calculated with the Wald chi2 test.

RESULTS

Elderly (>or=65 years), male, and nonwhite patients achieved GI-3 recovery later than younger (<65 years), female, and white patients (HR > 1 and P < .05 for all). Overall, alvimopan (12 mg) accelerated GI-3 recovery by 12 hours and GI-2 recovery by 17 hours compared with placebo. Within subgroups, regardless of covariate effect, patients who received alvimopan (12 mg) achieved GI-2 and GI-3 recovery sooner than patients who received placebo (HR > 1 and P < .05 for all).

CONCLUSIONS

These post hoc analyses support that alvimopan (12 mg) accelerates GI recovery across various patient populations.