Alvimopan for the reduction of postoperative ileus after long posterior spinal fusion: placebo-controlled double-blind randomized trial

OBJECTIVE

The aim of this study was to evaluate the efficacy of alvimopan administration after posterior spinal fusion (PSF) in adult spine surgery patients who are taking opioid agents.

METHODS

In this placebo-controlled, double-blind randomized trial, PSF patients were randomized in blocks to placebo or study drug. Primary and secondary outcome measures were return to normal bowel function, including time to passage of flatus and stool, time to tolerance of oral nutrition, and time to hospital discharge. Patients were included regardless of chronic opioid consumption status.

RESULTS

Thirty-one patients provided consent for participation, and 26 patients (13 per group) completed the study. There were no differences between groups with respect to time to flatus, time to bowel movement, time to oral nutrition tolerance, and time to discharge. Calculated effect sizes favored placebo for all interventions.

CONCLUSIONS

Alvimopan did not hasten return to bowel function for any primary or secondary outcome measures when compared with placebo for patients undergoing PSF. There were no adverse events related to alvimopan, including for patients with chronic opioid consumption. While underpowered to determine a statistical difference, it is unlikely that a clinically relevant effect exists.

Risk Factors for Post-operative Ileus: A Retrospective Study in Tertiary Referral Hospital in Indonesia

Background: Postoperative ileus is a complication that may result in the longer duration of stay and decreases the quality of life of patients. Previous studies have found some factors related to postoperative ileus. This study aimed to determine the risk factor of postoperative ileus in laparotomic resection and anastomosis surgery. Methods: Patients who underwent laparotomic resection and anastomosis surgery during January 2019 – July 2020 were included. Postoperative ileus was diagnosed in fourth day after surgery. The variables included in this study are age, gender, BMI, pathology site, duration of surgery, type of anastomosis, length of resection. Result: Fifty laparotomic resection and anastomosis surgery patients were included in this study, 50% of subjects is patients with postoperative ileus. Patient aged 65 years old or older had a higher incidence postoperative ileus (68% vs 28%; RR 2.3 95% CI: 1.23-4.33; p value: 0.010). Study also found duration of surgery 180 minutes or longer also had higher incidence postoperative ileus (79% vs 36%; RR: 2.49 95% CI: 1.20-5.15; p value: 0.010). Conclusion: This study concludes that age 65 years old or older and duration of surgery 180 minutes or longer are significant risk factor to postoperative ileus in laparotomic resection and anastomosis surgery patients.

A prospective randomized controlled trial to evaluate effect of chewing gum on postoperative ileus in elderly patient after hip fracture

Factors related to developing postoperative ileus (POI) vary from pharmacologic, inflammatory, hormonal, metabolic, gastrointestinal physiology, neurologic, to psychological factors. Although orthopedic-related incidence of postoperative ileus is about 10%, these studies are limited to spine surgery and pelvic surgery. The purpose of this study was to investigate prevalence of POI and to analyze effect of chewing gum on POI and bowel function in elderly patients after hip fracture surgery.A prospective randomized controlled trial was conducted at the Gyeongsang National University Hospital. Elderly patients with hip fracture who underwent surgery from March 2017 to June 2018 were eligible to participate. Patients were excluded if they had a mastication disability, impaired cognitive function, previous history of gastrointestinal disease, respiratory disease and low oxygen saturation, hip arthroplasty with causes other than hip fractures, acetabular fractures, periprosthetic fractures, or pathological fractures. Patients with consciousness problem by excessive anesthesia were also excluded. Patients were classified into 2 groups by randomization. Group I received sugar-free gum and were encouraged to chew 6 hours following surgery until the first intestinal gas is released. Group II was given the same postoperative procedure and encouraged to consume water after 6 hours.After applying exclusion criteria, 74 patients were finally included. Thirty-one patients were classified to Group I and 43 patients were classified to the Group II. Prevalence of POI in all patients with hip fracture was 63.5% (47/74). Prevalence of POI in Group I was statistically significant lower than that in Group II (Group I: 41%, Group II: 79.1%, P = .01)The prevalence of POI in elderly patients with hip fracture was 63.5%. Chewing gum had a significant effect on reduction of POI in elderly patients with hip fractures.

Risk factors for upper and lower type prolonged postoperative ileus following surgery for Crohn's disease

PURPOSE

Prolonged postoperative ileus (PPOI) is common after bowel resections, especially in Crohn's disease (CD). The pathophysiology of PPOI is not fully understood. PPOI could affect only the upper or lower gastrointestinal (GI) tract. The aim of this study was to assess risk factors for diverse types of PPOI, particularly to differentiate PPOI of upper and lower GI tract.

METHODS

A retrospective analysis of 163 patients with CD undergoing ileocecal resection from 2015 to 2020 in a single center was performed. PPOI of the upper GI tract was predefined as the presence of vomiting or use of nasogastric tube longer than the third postoperative day. Lower PPOI was predefined as the absence of defecation for more than three days. Independent risk factors were identified by multivariable logistic regression analysis.

RESULTS

Overall incidence of PPOI was 42.7%. PPOI of the upper GI tract was observed in 30.7% and lower PPOI in 20.9% of patients. Independent risk factors for upper PPOI included older age, surgery by a resident surgeon, hand-sewn anastomosis, prolonged opioid analgesia, and reoperation, while for lower PPOI included BMI ≤ 25 kg/m², preoperative anemia, and absence of ileostomy.

CONCLUSION

This study identified different risk factors for upper and lower PPOI after ileocecal resection in patients with CD. A differentiated upper/lower type approach should be considered in future research and clinical practice. High-risk patients for each type of PPOI should be closely monitored, and modifiable risk factors, such as preoperative anemia and opioids, should be avoided if possible.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Independent risk factors for prolonged postoperative ileus development

BACKGROUND

Postoperative ileus (POI) has a significant impact on patient wellbeing, and with a 15% incidence in colectomy patients costs US hospitals >$1.3 billion per year. Although some causative mechanisms have been identified, little is known about what places patients at risk for ileus. We aimed to identify factors that independently influence the development of POI.

MATERIALS AND METHODS

Patients who underwent elective surgery between 2011 and 2012 were identified from the colectomy-specific American College of Surgeons National Surgical Quality Improvement Program database. Descriptive statistics were calculated, and demographics, comorbidities, preoperative treatments, and operative characteristics were evaluated as risk factors using multivariate analyses.

RESULTS

A total of 9734 patients were included in this analysis; 1364 (14%) were found to have POI. Patients who developed an ileus were more likely to develop any postoperative complication, to be readmitted, and require reoperation compared with patients without POI. In addition, we identified 13 independent risk factors for POI.

CONCLUSIONS

Five modifiable risk factors for development of POI were identified as follows: smoking, weight loss, preoperative oral antibiotics, mechanical bowel preparation, and surgical approach. These identifications provide insight into possible targets for preoperative modification, which may lead to improvements in patients' quality of life and influence outcomes such as postoperative complications, readmission, and reoperation.

A systematic review of enhanced recovery care after colorectal surgery in elderly patients

AIM

Enhanced recovery after surgery (ERAS) can decrease complications and reduces hospital stay. Less certain is whether elderly patients can fully adhere to and benefit from ERAS. We aimed to determine the safety, feasibility and efficacy of enhanced recovery after colorectal surgery in patients aged ≥ 65 years old.

METHOD

A systematic search of Medline, EMBASE and Cochrane was performed to identify (i) studies comparing elderly patients managed with ERAS vs traditional care, (ii) cohort studies of ERAS with results of elderly vs younger patients and (iii) any case series of ERAS in elderly patients. End-points of interest were length of hospital stay, complications, mortality, readmission and re-operation, and ERAS protocol adherence.

RESULTS

Sixteen studies were included. Two randomized controlled trials demonstrated shorter hospital stay in elderly patients with ERAS compared with elderly patients with non-ERAS (9 vs 13.2 days, P < 0.001; 5.5 vs 7 days, P < 0.0001). Fewer complications occurred with ERAS in both randomized controlled trials (27.4% vs 58.6%, P < 0.0001; 5% vs 21.1%, P = 0.045). The majority of observational studies did not show differences in outcome between elderly and younger patients in terms of hospital stay, morbidity or mortality. Inconsistent findings between cohort studies may reflect the disparities in ERAS protocol definitions or differences in study populations.

CONCLUSION

ERAS can be safely applied to elderly patients to reduce complications and shorten length of hospital stay. Further studies are required to assess whether elderly patients are able to adhere to, and benefit from, ERAS protocols to the same extent as younger patients.

Identification of clinical outcome measures for recovery of gastrointestinal motility in postoperative ileus

OBJECTIVE

To identify clinical hallmarks associated with recovery of gastrointestinal transit.

BACKGROUND

Impaired gastrointestinal transit or postoperative ileus largely determines clinical recovery after abdominal surgery. However, validated clinical hallmarks of gastrointestinal recovery to evaluate new treatments and readiness for discharge from the hospital are lacking.

METHODS

Gastric emptying and colonic transit were scintigraphically assessed from postoperative day 1 to 3 in 84 patients requiring elective colonic surgery and were compared with clinical parameters. The clinical hallmark that best reflected recovery of gastrointestinal transit was validated using data from a multicenter trial of 320 segmental colectomy patients.

RESULTS

Seven of 84 patients developed a major complication with paralytic ileus characterized by total inhibition of gastrointestinal motility and were excluded from further analysis. In the remaining patients, recovery of colonic transit (defined as geometric center of radioactivity ≥2 on day 3), but not gastric emptying, was significantly correlated with clinical recovery (ρ = -0.59, P < 0.001). Conversely, the combined outcome measure of tolerance of solid food and having had defecation (SF + D) (area under the curve = 0.9, SE = 0.04, 95% CI = 0.79-0.95, P < 0.001), but not time to first flatus, best indicated recovery of gastrointestinal transit with a positive predictive value of 93% (95% CI = 78-99). Also in the main clinical trial, multiple regression analysis revealed that SF + D best predicted the duration of hospital stay.

CONCLUSIONS

Our data indicate that the time to SF + D best reflects recovery of gastrointestinal transit and therefore should be considered as primary outcome measure in future clinical trials on postoperative ileus.(Netherlands National Trial Register, number NTR1884 and NTR222).

Risk factors for the development of prolonged post-operative ileus following elective colorectal surgery

PURPOSE

Prolonged post-operative ileus (PPOI) increases post-operative morbidity and prolongs hospital stay. An improved understanding of the elements which contribute to the genesis of PPOI is needed in the first instance to facilitate accurate risk stratification and institute effective preventive measures. The aim of this retrospective cohort study was to therefore determine the perioperative risk factors associated with development of PPOI.

METHODS

All elective intra-abdominal operations undertaken by the Colorectal Unit at Auckland District Health Board from 1 January to 31 December 2011 were accessed. Data were extracted for an assortment of patient characteristics and perioperative variables. Cases were stratified by the occurrence of clinician-diagnosed PPOI. Univariate and regression analyses were performed to identify correlates and independent risk factors, respectively.

RESULTS

Two hundred and fifty-five patients were identified of whom 50 (19.6%) developed PPOI. The median duration for PPOI was 4 days with 98% resolving spontaneously with conservative measures. Univariate analysis identified increasing age; procedure type; increasing opiate consumption; elevated preoperative creatinine; post-operative haemoglobin drop, highest white cell count and lowest sodium; and increasing complication grade as significant correlates. Logistic regression found increasing age (OR 1.032, 95% CI 1.004-1.061; p = 0.026) and increasing drop in pre- to post-operative haemoglobin (OR 1.043, 95% CI 1.002-1.085; p = 0.037) as the only independent predictors for developing PPOI. An important limitation of this study was its retrospective nature.

CONCLUSIONS

Increasing age and increasing drop in haemoglobin are independent predictors for developing PPOI. Prospective assessment is required to facilitate more accurate risk factor analysis.