Intraoperative continuous intestinal loop warming technique A prospective randomised trial

AIM

The aim of this study is to evaluate if the Intraoperative Continuous Intestinal Loop Warming (ICLW) is a valid trick to decrease the postoperative paralytic ileus.

METHODS

The subjects were patients who underwent emergency open abdominal surgery for either benign or malignant diseases. Patients were divided into two groups; group A patients who was secluded for ICLW, and a control group B who was not secluded for ICLW. The primary outcomes were the time of recovery of bowel movement, 30 days postoperative mortality and morbidity, morbidity was graded by the Clavien-Dindo classification of surgical complications. Secondary outcomes were operative time, and length of hospital stay.

RESULTS

A total numbers of 100 patients were randomly assigned in this prospective study. The mean time of bowel function recovery in the group A was 41.52 hours, whereas for group B was 67.20 hours, these differences were statistically significant with a P value < 0.05. In group B the bowel function recovery for 64% of the patients took between 72-96 hours furthermore, the longest time for peristaltic recovery was 96 hours which was only observed in patients of group B. There were no intra-operative complication in both groups. There is no difference in the two groups in term of 30 day postoperative morbidity.

CONCLUSIONS

Intra-operative continuous intestinal loop warming technique is a simple, safe and low cost technique. It seems that intra-operative continuous intestinal loop warming technique maintain tissues hydration and conserve the body temperature limiting the stress response and help in decreasing the incidence of postoperative paralytic ileus.

KEY WORDS

Paralytic Ileus, Postoperative Care, Warming.

Paralytic Ileus and Prophylactic Gastrointestinal Motility Medication after Spinal Operation

PURPOSE

To investigate the prevalence of paralytic ileus after spinal operation in the supine or prone operative position and to determine the efficacy of prophylactic gastrointestinal motility medications in preventing symptomatic paralytic ileus after a spinal operation.

MATERIALS AND METHODS

All patients received spinal surgery in the supine or prone operative position. The study period was divided into two phases: first, to analyze the prevalence of radiographic and symptomatic paralytic ileus after a spinal operation, and second, to determine the therapeutic effects of prophylactic gastrointestinal motility medications (postoperative intravenous injection of scopolamine butylbromide and metoclopramide hydrochloride) on symptomatic paralytic ileus after a spinal operation.

RESULTS

Basic demographic data were not different. In the first phase of this study, 27 patients (32.9%) with radiographic paralytic ileus and 11 patients (13.4%) with symptomatic paralytic ileus were observed. Radiographic paralytic ileus was more often noted in patients who underwent an operation in the prone position (p=0.044); whereas the occurrence of symptomatic paralytic ileus was not different between the supine and prone positioned patients (p=0.385). In the second phase, prophylactic medications were shown to be ineffective in preventing symptomatic paralytic ileus after spinal surgery [symptomatic paralytic ileus was observed in 11.1% (4/36) with prophylactic medication and 16.7% (5/30) with a placebo, p=0.513].

CONCLUSION

Spinal surgery in the prone position was shown to increase the likelihood of radiographic paralytic ileus occurrence, but not symptomatic paralytic ileus. Unfortunately, the prophylactic medications to prevent symptomatic paralytic ileus after spine surgery were shown to be ineffective.

Multicentre, randomised, placebo-controlled trial of extract of Japanese herbal medicine Daikenchuto to prevent bowel dysfunction after adult liver transplantation (DKB 14 Study)

INTRODUCTION

This multicentre randomised controlled clinical trial will aim to determine the ability of an extract (TJ-100) of Daikenchuto (traditional Japanese herbal medicine; Kampo) to prevent bowel dysfunction in at least 110 patients after liver transplantation (LT).

METHODS AND ANALYSIS

The following co-primary end points will be evaluated on postoperative day 7: total oral and enteral caloric intake, abdominal distension and abdominal pain. The secondary end points will comprise sequential changes of total oral and enteral caloric intake after LT, sequential changes in numeric rating scales for abdominal distension and pain, elapsed time to the first postoperative passage of stool, quality of life assessment using the Gastrointestinal Symptom Rating Scale score (Japanese version), postoperative liver function, liver regeneration rate, incidence of bacteraemia and bacterial strain, trough level of immunosuppressants, occurrence of acute cellular rejection, discharge or not within 2 months after LT, sequential changes of portal venous flow to the graft and ascites discharge. The two arms of the study will comprise 55 patients per arm.

ETHICS AND DISSEMINATION

The study has been conducted according to the CONSORT statement. All participants signed a written consent form, and the study has been approved by the institutional review board of each participating institute and conducted in accordance with the Declaration of Helsinki of 1996. The findings will be disseminated through scientific and professional conferences, and in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

The DKB 14 Study was registered in the University Hospital Medical Information Network Clinical Trial Registration (UMIN-CTR), Japan (registration number: UMIN000014326) during 2014.

Perioperative administration of Daikenchuto (TJ-100) reduces the postoperative paralytic ileus in patients with pancreaticoduodenectomy

BACKGROUND/AIMS

No study has reported whether perioperative administration of Daikenchuto (TJ-100) reduced paralytic ileus after pancreaticoduodenectomy (PD).

METHODOLOGY

Forty-five consecutive patients that were scheduled to undergo PD at Wakayama Medical University Hospital between August 2010 and August 2011 were enrolled in this study including the first cohort (n = 15) as the control group and the subsequent cohort (n = 30) as the TJ-100 group. This trial was registered at UMIN-CTR ID# 000005056.

RESULTS

Postoperative paralytic ileus occurred more frequently in the control group (73.3% of the control group and 20.0% of the TJ-100 group; p = 0.001). The first passages of flatus significantly improved earlier in the TJ-100 group than in the control group (p = 0.014). A multiple cytokine assay of the drainage and serum showed that IL-9 and IL-10 in the drainage was significantly higher on postoperative day 1 in the TJ-100 group. There were no complications associated with the preoperative administration of TJ-100 before surgery, and no significant differences were observed between the two groups in the incidence of postoperative Gradel-2 diarrhea (CTCAE4.0).

CONCLUSIONS

Perioperative administration of TJ-100 was feasible and reduced the incidence of paralytic ileus in PD, and further randomized controlled trials should be conducted.

Retinoblastoma protein prevents enteric nervous system defects and intestinal pseudo-obstruction

The retinoblastoma 1 (RB1) tumor suppressor is a critical regulator of cell cycle progression and development. To investigate the role of RB1 in neural crest-derived melanocytes, we bred mice with a floxed Rb1 allele with mice expressing Cre from the tyrosinase (Tyr) promoter. TyrCre+;Rb1fl/fl mice exhibited no melanocyte defects but died unexpectedly early with intestinal obstruction, striking defects in the enteric nervous system (ENS), and abnormal intestinal motility. Cre-induced DNA recombination occurred in all enteric glia and most small bowel myenteric neurons, yet phenotypic effects of Rb1 loss were cell-type specific. Enteric glia were twice as abundant in mutant mice compared with those in control animals, while myenteric neuron number was normal. Most myenteric neurons also appeared normal in size, but NO-producing myenteric neurons developed very large nuclei as a result of DNA replication without cell division (i.e., endoreplication). Parallel studies in vitro found that exogenous NO and Rb1 shRNA increased ENS precursor DNA replication and nuclear size. The large, irregularly shaped nuclei in NO-producing neurons were remarkably similar to those in progeria, an early-onset aging disorder that has been linked to RB1 dysfunction. These findings reveal a role for RB1 in the ENS.

[Application of Sorbilact in the treatment and prophylaxis of postoperative intestinal paresis after reconstructive operations on the biliary ducts]

The activity of complex preparation Sorbilact was studied up in the patients, suffering obturative jaundice after surgical interventions on hepatopancreatoduodenal zone organs. Preparation Sorbilact causes antishock, proenergetic, desintoxication, diuretic and procinetic intestinal effects. The Sorbilact inclusion in complex of postoperative treatment of patients secures possibility of early administration of the enteral probe nutrition, promotes the trophic state optimization as well as the rehabilitation period duration shortening.

Systematic review and meta-analysis of chewing-gum therapy in the reduction of postoperative paralytic ileus following gastrointestinal surgery

BACKGROUND

Postoperative ileus has long been considered an inevitable consequence of gastrointestinal surgery. It prolongs hospital stay, increases morbidity, and adds to treatment costs. Chewing is a form of sham feeding reported to stimulate bowel motility. This analysis examines the value of chewing-gum therapy in treatment of postoperative ileus.

METHODS

A search for randomized, controlled trials studying elective gastrointestinal surgery was undertaken using MEDLINE, Embase, Cochrane Controlled Trials Register, and reference lists. Outcomes were extracted including time to first flatus and bowel motion, length of stay, and complications. Statistical analysis was undertaken using the weighted mean difference (WMD) and random-effects model with 95% confidence intervals (CI).

RESULTS

Seven studies with 272 patients were included. For time to first flatus the analysis favored treatment with a WMD of 12.6 h (17%) reduction (95% CI -21.49 to -3.72; P = 0.005). For time to first bowel motion, treatment was favored with a WMD of 23.11 h (22%) reduction (95% CI -34.32 to -11.91; P < 0.001). For length of stay, the analysis showed a nonsignificant trend toward treatment with WMD of 23.88 h (12%) reduction (95% CI -53.29 to +5.53; P = 0.11). There were no significant differences in complication rates.

CONCLUSIONS

Chewing-gum therapy following open gastrointestinal surgery is beneficial in reducing the period of postoperative ileus, although without a significant reduction in length of hospital stay. These outcomes are not significant for laparoscopic gastrointestinal surgery.

Comparison of methods to facilitate postoperative bowel function

Improving postoperative return of bowel function after abdominal surgery is an important nursing and medical goal. One promising intervention to achieve this goal is to have patients chew gum several times per day in the early postoperative period to stimulate the cephalic-vagal reflex and bowel peristalsis. A study to determine if return of gastrointestinal function after abdominal surgery could be hastened by the simple intervention of chewing gum or sucking on hard candy three times per day is described.

[Methods to protect the spinal cord and visceral organs in surgery of distal aortic dissections]

The problem of protecting the spinal cord and visceral organs in surgery of distal aortic dissections becomes increasingly important today because of a comparatively high incidence rate of complications. Paraparesis in type 3 dissecting aortic aneurysm (DAA) is noted to occur in ischaemia of the spinal cord lasting more than 56.5+/-12 min and the inclusion into the blood flow of less than two responsible intercostal arteries. Multiple-organ insufficiency in type 3 DAA is observed in ischaemia of the visceral organs lasting more than 36.4+/-6.9 min. While using profound hypothermia and circulatory arrest, fatal haemorrhage appears when the duration of the hypothermic arrest is more than 48+/-13.5 min. The used methods aimed at protecting the spinal cord and visceral organs (perfusion-free technique with cerebrospinal fluid drainage, left artio-femoral bypass, circulation arrest with deep hypothermia), optimization of the scope and technique of the operation, shortened duration of ischaemia, inclusion of the maximum number of the spinal arteries into the blood flow, the use of the system of collection and return of blood make it possible to expect a decreased number of complications.

Minimizing antipsychotic medication obviated the need for enema against severe constipation leading to paralytic ileus: a case report

OBJECTIVE

To report the usefulness of antipsychotic dose-reduction for avoiding paralytic ileus in a patient with chronic schizophrenia and comorbid dementia.

CASE SUMMARY

A 65-year-old in-patient developed severe paralytic ileus warranting a transfer to the general hospital. Constipation was very troublesome and he often needed enema to prevent intestinal obstruction. He had originally been treated with 24 mg of bromperidol, which was reduced to 4 mg, and other psychotropic treatments were simultaneously simplified. As a result, bowel habits improved and enema is now only rarely necessary. Constipation is a frequent adverse effect of antipsychotics and adjunctive psychotropics, which can be severe and may lead to life-threatening paralytic ileus. Dose-reduction obviated a necessity of enema against persistent constipation, while the patient's mental status remained under control. Assessment using the Naranjo probability scale revealed a definite causal relationship.

DISCUSSION

With an increasing number of elderly patients with schizophrenia, more cases of severe gastrointestinal motility problems from antipsychotic medication are to be expected. In this patient population dose-reduction of antipsychotics and simplification of concomitant psychotropics should be seriously considered.

Multimodal perioperative plan for radical cystectomy and intestinal urinary diversion. I. Effect on recovery of intestinal function and occurrence of complications

OBJECTIVES

To discuss a multimodal perioperative plan aimed at reducing postoperative ileus and complications associated with radical cystectomy and urinary reconstruction.

METHODS

The protocol consisted of preoperative, intraoperative, and postoperative measures. The clinical parameters assessed were the time to the return of bowel movements, the presence and duration of postoperative ileus, the presence and duration of an intolerance to oral feeding, the interval to re-institution of a regular diet, and complications. The biochemical parameters (serum total protein and albumin levels and lymphocyte counts) were also assessed. A sample of 40 patients treated before the implementation of this protocol was included for comparison.

RESULTS

A total of 71 patients, mean age 74 years and American Society of Anesthesiologists status 2 and 3, consecutively underwent radical surgery for bladder cancer and were evaluable for results and complications. Urinary diversion was a heterotopic neobladder in 27 patients (38%), orthotopic in 23 (32.3%), and an ileal conduit in 21 (29.5%). Bowel movements returned after a median of 2 days (range 1 to 6), intolerance to oral feeding was observed in 17 (23.9%) of 71 patients, and the median time to re-institution of a regular diet was 4 days (range 3 to 9). The complication rate was 26.7%, and the mortality rate was 4.2%. No effects were observed on postoperative protein depletion. In the historical group, the median time to diet resumption was 8 days (range 7 to 12).

CONCLUSIONS

A short time to the resumption of normal intestinal function and a low incidence of postoperative ileus after cystectomy was observed. However, the incidence of postoperative protein depletion was unaffected. Additional studies should address this subject.

Prevention of gastrointestinal complications in the critically ill patient

Common pathophysiologic changes associated with critical illness directly contribute to the development of gastrointestinal (GI) complications. In addition, supportive interventions such as mechanical ventilation and vasopressors increase the risk of GI complications. Early, specific signs of GI complications are rarely present; therefore, because of late or missed diagnosis, morbidity and mortality related to these complications can be high. This article aims to review the pathophysiology of GI dysfunction and describe an approach to evaluate the abdomen in the critically ill patient. Risk can be limited by understanding individual patient characteristics, thoughtfully evaluating the risk-benefit profile of all interventions, and implementing preventive strategies.

Da-Cheng-Qi-Tang promotes the recovery of gastrointestinal motility after abdominal surgery in humans

In order to examine the effects of Da-Cheng-Qi-Tang (DCQT) on gastrointestinal motility functions after abdominal surgery in humans, 33 patients with abdominal surgeries and 36 patients with cholecystectomies were divided into the DCQT and the control groups at random. Electrogastrography (EGG) and gastroduodenojejunal manometry was performed and the levels of plasma motilin were measured by radioimmunoassay. The results were as follows: (1) on the day of surgery, the ratio of EGG normal frequency in the DCQT group was higher than in the control group (P=0.0016); (2) the power of EGG in the DCQT group was higher than in the control group on the second and third days after surgeries (P=0.0011 and P=0.0215, respectively); (3) the percentage of normal bowel peristalsis was significantly higher in the DCQT group than in the control group (P<0.01); and (4) in the DCQT group, the plasma motilin level reached its peak earlier than in the control group. Our results suggest that DCQT can increase plasma motilin, enhance gastrointestinal motility, improve gastric dysrythmia, and reduce gastroparesis after abdominal surgery.

Does gum chewing help prevent impaired gastric motility in the postoperative period?

PURPOSE

To discuss the pathophysiology of postoperative ileus (POI) and the addition of gum chewing to a multimodal treatment plan.

DATA SOURCES

Review of current literature of the pathophysiology of POI, multimodal treatment options, and current research on gum chewing and its effects on the prevention of POI.

CONCLUSIONS

Studies have documented that gum chewing decreases time to flatus and first defecation after surgery. Studies indicate that gum chewing can decrease the length of hospital stay by 1 day. There were no documented adverse effects of gum chewing. The addition of gum chewing to a multimodal treatment program assists with increasing patient comfort, satisfaction, and decreasing healthcare expenditures.

IMPLICATIONS FOR PRACTICE

POI is a common complication of abdominal surgery. Research has indicated that gum chewing has assisted with increasing gastric motility, decreasing lengths of hospital stays, and decreasing healthcare expenditures. Gum chewing is an inexpensive and safe option to add to a multimodal program for the prevention of POI.

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.

["Fast-track surgery": Perioperative management]

The multimodal therapeutic concept of fast-track surgery is directed against the pathophysiologic functional changes following elective surgery. This concept has been proven to reduce postoperative morbidity and convalescence. This benefit is based on an interdisciplinary approach by surgeons, anaesthesiologists, nurses, and physiotherapy staff to optimise perioperative care in order to decrease surgically-induced stress. Fast-track surgery after elective colorectal surgery has been shown to reduce the rate of postoperative complications and shorten hospital stay significantly. A prerequisite for successfully implementing this concept is the willingness of the participating surgeons to abandon conventional traditions. In addition to abdominal procedures, the basic concept of fast-track surgery has been successfully instituted in other surgical fields, such as urology.

[Ganglionic blockers in abdominal surgery: facts and hypotheses. 2.Clinical, pathophysiological and pharmacological aspects of ganglionic blocker use]

The authors discuss facts and hypotheses on the effects of benzohexonium upon the motor activity of the intestine and the significance of N-cholinolytics for prophylactics and treatment of postoperative pareses of the gastrointestinal tract. The ganglioblockers possess antistress effect, reduce the degree of pathological vegetative reactions and facilitate realization of the mechanisms of selfregulation of functions of the small and large intestine. Using benzohexonium during operation and in the first days after it makes the intestinal pareses less frequent. N-cholinolytics however do not have a considerable stimulating influence on the contracting activity of the gastrointestinal tract that accounts for their not high effectiveness in treatment of early functional motor evacuatory disorders. The points of action of gangliolytics, those at the level of the intestinal wall included, can not be considered to be completely established, as well as the mechanisms of their indirect effect. The ganglionic blockade should be considered as the basic method of prophylactics of the postoperative paresis of the intestine.

COX-2 dependent inflammation increases spinal Fos expression during rodent postoperative ileus

BACKGROUND AND AIMS

Cyclooxygenase 2 (COX-2) and prostaglandins (PGs) participate in the pathogenesis of inflammatory postoperative ileus. We sought to determine whether the emerging neuronal modulator COX-2 plays a significant role in primary afferent activation during postoperative ileus using spinal Fos expression as a marker.

METHODS

Rats, and COX-2(+/+) and COX-2(-/-) mice underwent simple intestinal manipulation. The effect of intestinal manipulation on Fos immunoreactivity (IR) in the L(5)-S(1) spinal cord, in situ circumference, and postoperative leucocytic infiltrate of the intestinal muscularis was measured. Postoperative PGE(2) production was measured in peritoneal lavage fluid. The dependence of these parameters on COX-2 was studied in pharmacological (DFU, Merck- Frosst, selective COX-2 inhibitor) and genetic (COX-2(-/-) mice) models.

RESULTS

Postoperative Fos IR increased 3.7-fold in rats and 2.2-fold in mice. Both muscularis leucocytic infiltrate and the circumference of the muscularis increased significantly in rats and COX-2(+/+) mice postoperatively, indicating dilating ileus. Surgical manipulation markedly increased PGE(2) levels in the peritoneal cavity. DFU pretreatment and the genetic absence of COX-2(-/-) prevented dilating ileus, and leucocytic infiltrate was diminished by 40% with DFU and by 54% in COX-2(-/-) mice. DFU reversed postsurgical intra- abdominal PGE(2) levels to normal. Fos IR after intestinal manipulation was attenuated by approximately 50% in DFU treated rats and in COX-2(-/-) mice.

CONCLUSIONS

Postoperatively, small bowel manipulation causes a significant and prolonged increase in spinal Fos expression, suggesting prolonged primary afferent activation. COX-2 plays a key role in this response. This activation of primary afferents may subsequently initiate inhibitory motor reflexes to the gut, contributing to postoperative ileus.

Effect of epidural analgesia on postoperative paralytic ileus in chronic schizophrenia

BACKGROUND AND OBJECTIVES

Postoperative paralytic ileus is frequently encountered in chronic schizophrenic patients who undergo abdominal surgery. We investigated whether epidural analgesia with local anesthetics minimizes postoperative ileus in schizophrenic patients who are treated long term with antipsychotic drugs.

METHODS

We measured the VAS pain after surgery and the time that elapsed before the first passage of flatus and/or feces after the end of surgery in schizophrenic patients provided analgesia with systemic buprenorphine (group A) and schizophrenic patients receiving epidural analgesia with local anesthetics (group B).

RESULTS

The frequency of patients who did not pass flatus and/or feces for more than 120 hours postoperatively was significantly higher in group A. Postoperative pain scores of group A at 8 and 24 hours after the end of anesthesia were 36.0 +/- 12.8 and 31.7 +/- 10.7 (0 to 100 mm scale), which were significantly higher than 25.4 +/- 13.2 and 20.5 +/- 9.4 scores in group B.

CONCLUSIONS

Epidural analgesia with local anesthetics in chronic schizophrenic patients undergoing abdominal surgery minimizes postoperative ileus compared to patients receiving systemic buprenorphine.

[Nasogastric tubes after elective abdominal surgery is not justified]

There is no need for systematic nasogastric tube after elective abdominal and digestive surgery. Expected benefits are comfort for the patient, reduction of pulmonary morbidity, and rapid oral feeding. Only 5% of the patients will need a subsequent placement of nasogastric tube, due to vomiting and abdominal distention, with no adverse effects.

Postoperative management of cesarean patients: the effect of immediate feeding on the incidence of ileus

OBJECTIVE

To evaluate the effect of immediate feeding on gastrointestinal function in patients undergoing cesarean delivery.

METHODS

A prospective study was conducted in which patients were randomized to one of two groups, either early feeding or delayed feeding, ie, feeding according to the institution's current protocol. Questionnaires were filled out by the subjects on the day of discharge. Fisher exact test was used to compare the two groups with respect to the type of anesthetic used and to compare the incidence of gastrointestinal symptoms. A one-sided exact binomial confidence interval was used to determine the upper bound of the likelihood of paralytic ileus. Logistic regression analysis was used to evaluate the presence of ileus symptoms when controlling for the type of anesthetic used.

RESULTS

There were no significant differences between the control and study groups. There was no significant difference in the number of gastrointestinal symptoms between the two groups. The incidence of postoperative paralytic ileus was zero in both the study and control groups.

CONCLUSION

Routine early feeding of subjects undergoing cesarean delivery can be implemented without an increase in gastrointestinal symptoms or paralytic ileus.

Postoperative enteral hyperalimentation results in earlier elevation of serum branched-chain amino acid levels

To objectively document the immediate maintenance and successful exploitation of postoperative gastrointestinal (GI) function, elemental diet was infused into the more distal duodenum of 30 cholecystectomy patients at 300 kcal per hour, beginning on arrival at the recovery room. Approximately 4,600 kcal and 190 grams of amino acids were absorbed during the initial 16 hours. Serum branched-chain amino acids (BCAAs) had risen above basal levels at 4 hours, statistically significant only for leucine (+64%). The higher concentrations had reached statistical significance for all BCAAs by 6 hours, when leucine had risen by 83%, isoleucine by 54%, and valine by 47%. The elevated BCAA and glucose levels sustained throughout the hyperalimentation period objectively verify that postoperative GI function can be safely exploited, and may contribute to improved wound healing and sepsis resistance.

Oncotic pressure, albumin and ileus: the effect of albumin replacement on postoperative ileus

The effect of decreased colloid oncotic pressure, as seen in hypoalbuminemia and hypoproteinemia, upon intestinal function has been well delineated in the surgical literature. Patients undergoing abdominal aortic aneurysm resection or aortoiliac or aortofemoral bypass grafts are almost uniformly hypoalbuminemic postoperatively; with these two facts in mind, a prospective, randomized clinical study was undertaken to identify the role of serum albumin concentration on the length of postoperative ileus in this population. The main hypothesis was that patients whose albumin levels dropped below 3.5 gm/dL would have a more prolonged postoperative hospital course as a result of delay in return of bowel function when compared with those patients in whom the low albumin levels were exogenously acutely replenished to > 3.5 gm/dL. Albumin was replaced to a level greater-than or equal to 3.5 g/dL in one group of 37 patients (AR), with a control group of 32 patients (NR) not receiving any albumin. Return of bowel function was measured by the postoperative day that flatus was documented, as well as the postoperative day oral intake was resumed. Mean values were determined for each group, and t tests did not reveal a significant difference in postoperative day of flatus (AR mean = 4.06 days, NR mean = 4.16 days) or postoperative day of oral intake (AR mean = 4.0, NR mean = 3.75). Additional comparisons between the groups involving the number of postoperative days until a regular diet was begun (AR mean = 6.06, NR mean = 5.48) and length of postoperative hospital stay (AR mean = 9.16, NR mean = 8.43) failed to reveal significant differences.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of preoperative suggestion on postoperative gastrointestinal motility

Autonomic behavior is subject to direct suggestion. We found that patients undergoing major operations benefit more from instruction than from information and reassurance. We compared the return of intestinal function after intra-abdominal operations in 2 groups of patients: the suggestion group received specific instructions for the early return of gastrointestinal motility, and the control group received an equal-length interview offering reassurance and nonspecific instructions. The suggestion group had a significantly shorter average time to the return of intestinal motility, 2.6 versus 4.1 days. Time to discharge was 6.5 versus 8.1 days. Covariates including duration of operation, amount of intraoperative bowel manipulation, and amount of postoperative narcotics were also examined using the statistical model analysis of covariance. An average savings of $1,200 per patient resulted from this simple 5-minute intervention. In summary, the use of specific physiologically active suggestions given preoperatively in a beleivable manner can reduce the morbidity associated with an intra-abdominal operation by reducing the duration of ileus.

[Prevention and therapy of postoperative paralytic ileus]

An analysis of the course of the postoperative period has shown that continuous mesenterial retroperitoneal novokain blockade is considerably more effective than medicamentous methods of prophylactics and treatment of postoperative paresis of the intestine, it has a good anesthetizing effect. When using the blockade the intestine function was completely reestablished in 111 (92.5%) patients operated upon.

Pharmacological manipulation of postoperative intestinal adhesions

Paralytic ileus and intestinal adhesions are common events following intra-abdominal surgery. The theoretical hypothesis 'that stimulation of the postoperative bowel will reduce intestinal adhesions' was studied in a rat model for intestinal adhesions in which postoperative bowel motility was pharmacologically manipulated. Immediate postoperative stimulation of gastrointestinal motility by the prokinetic agent, Cisapride, resulted in a significant reduction in both the number and extent of adhesions. Inhibition of postoperative intestinal motility with the anticholinergic agent, atropine, resulted in a greater number of more dense adhesions involving an increased length of bowel.

[Is nasogastric drainage effective in the control of paresis after operations on the colon and rectum?]

The investigation was designed for the assessment of efficiency of nasogastral drainage to struggle against intestinal paresis after operations on the colon and rectum. Under analysis was a group of 102 patients. It was established that the nasogastral drainage in those patients not only failed to exert a favorable effect on the reestablishment of motor-evacuatory function of intestines but in some cases it made paresis longer. The authors have shown the prolonged use of nasogastral probes to increase the amount of pulmonary complications in such patients.

[Multi-channel programmed electric stimulation in the prevention of complications after pancreatoduodenal resection]

Based on investigation of the course of the postoperative period in 144 patients after pancreatoduodenal resection the authors have developed a complex of measures aimed at earlier recovery of motility of the digestive tract including the following: blockade of pain impulses from the operated area, disloading of the gastrointestinal tract with the help of permanent jejunal probe, pharmacological stimulation of peristalsis, direct programmed electrostimulation of the intestines. The application of it results in the recovery of peristalsis in the 2nd-3d days after operation and in less amount of postoperative complications.

[Gastrointestinal complications and their prevention after abdominal aortic reconstruction, especially factors and prevention of paralytic intestinal ileus after a abdominal bifurcated grafting operation]

We experienced 66 cases of abdominal aortic repair, which contained 49 cases of abdominal aortic aneurysm (AAA) and 17 cases of high leveled arteriosclerotic occlusion (high ASO), since March, 1977 till December, 1985. Operative procedures were 44 cases of Y-graft replacement and 5 cases of tube graft interposition for all of AAA, and Y bypass grafting for high ASO. As early gastrointestinal complications after these repairs, paralytic intestinal ileus was found 9 cases in AAA group and no case in high ASO group. Mechanical intestinal ileus needed surgical lysis was found one case in AAA group and one case in high ASO group, upper gastrointestinal bleeding was found 2 cases in both groups, transient ischemic colitis 4 cases in AAA group, and liver dysfunction 4 cases in AAA group. The most frequent complication was paralytic intestinal ileus. In the comparison between 9 cases of paralytic intestinal ileus and others, operative time of the former was significantly longer than that of the latter. But there were no differences in the incidence of other factors. We think that, operative procedure must be chosen in consideration of shortening the operative time. And careful management of gastrointestinal tract and pre-operative correction of general conditions, especially the correction of serum electrolytes and nutrition are the most important.

Failure of epidural anesthesia to prevent postoperative paralytic ileus

This study used radiopaque markers and serial abdominal radiographs to assess the effect of epidural anesthesia on postoperative colonic ileus. Epidural anesthesia did not result in significantly faster return of propulsive motility in the colon after surgery as compared with control (P greater than 0.05). In addition, no significant difference was seen between the groups in colonic transit time and time for the first passage of gas and feces. The level of inhibition of sympathetic efferent nerves to the abdominal cavity was assessed by repeated measurements of blood glucose levels during the first postoperative day. Blood glucose levels were found to be significantly lower in the epidural group, demonstrating an inhibition of efferent sympathetic nerves below the level of T-5. Results show lack of effect of continuous epidural anesthesia in the prevention of postoperative paralytic ileus and suggest that mechanisms other than spinal reflexes play a major part in the development and maintenance of intestinal paralysis.

[Prevention of dynamic intestinal obstruction in children with peritonitis]

In order to prevent the development of the dynamic intestinal obstruction the prolonged peridural blockade, intravenous and intraaortal injection of the solution of novocain were used with reference to the phase of the pathological process. Results of the examination of 200 patients has shown that these measures facilitate passage of flatus and stools, shortens the staying of the patients at the hospital and reduces the amount of postoperative complications and lethality.

[A technic to avoid postoperative intestinal hypodynamia]

The hypodynamic postoperative ileus in children, has as main cause the circle gastric distension-reflex intestinal ileus, produced by the swallowed air. The gastric emptying system-through a Levin tube from the stomach is not usually sufficient to get off all the swallowed air. Nevertheless, a continuous suction from the lower third of oesophagus, through a double lumen sump tube is twelve times more effective in the getting off de air before it comes into the stomach, without need of a nasogastric tube.

Dihydroergotamine--stimulation of intestinal peristalsis. An experimental and clinical study

In an experimental study in 15 beagle hounds using strain gauges a significantly increased motility in the small and large intestine after dihydroergotamine was observed. Since this assessment did not provide any information about mucus transport, gastro-intestinal passage time in patient and control groups was determined using radioopaque catheter material. While transit time in the patient group was significantly reduced by 2 x 0.5 mg DHE s.c./day, this effect was not observed in controls. We related the significantly reduced passage time after DHE in the patient group to a normalisation of a functional disturbance of regulation. The action of the drug is seen in the blocking of the stress induced increased sympathetic tone, without the side effects often seen after pure alpha-antagonists of the phentolamine type or the adrenergic guanethidine type neuronal blocking agents. The specific efficacy of DHE as a partial alpha-antagonist is pointed out. For the clinician, postoperative gastro-intestinal atony might be an indication for its use.

[Prevention of paralytic ileus after colonic surgery by continuous peridural sympathetic block. Preliminary report]

Gastrointestinal atony must be considered as a reflex response to surgical intervention, due to activation of sympathetic nerves. Following colonic surgery, the duration of this response may be notably extended and the ensuing intestinal distension becomes the paramount factor of a persisting ileus. Blocking the sympathetic fibers prevents intestinal distension. Introducing appropriate catheter into the peridural space up to the level of the 10th--11th thoracic vertebra makes it possible to realize a segmental continuous block between T6--L2, where gastrointestinal sympathetic innervation actually originates. Using bupivacaine at low concentration (0.125% with epinephrine 1/400,000) reduces untoward effect on circulation and may even prove beneficial if volaemia is effective. In addition, it produces a selective block on the visceromotor fibers which allows a differential diagnosis of the ileus, without risking to pass over a perforation of the gut whenever a coexisting mechanical factor is suspected.