Postoperative ileus

Postoperative ileus after para-aortic lymphadenectomy: A prospective study

OBJECTIVE

To evaluate GI symptoms in patients submitted to systematic para-aortic lymphadenectomy (PALN) and to compare them in a contemporary series of patients only submitted to systematic pelvic lymphadenectomy (PLN).

METHODS

A prospective study of 51 consecutive patients submitted to systematic (minimum number of aortic nodes removed > or =10) laparotomic para-aortic lymphadenectomy for any gynecological cancer. The following parameters have been monitored prospectively: nausea and vomiting, bowel movements, nasogastric tube insertion or reinsertion, the time of removal of the nasogastric tube, duration of ileus, time to first passage of stool, regular diet consumption and postoperative stay and complications.

RESULTS

Twenty-three of 46 valuable patients (50%) submitted to systematic para-aortic lymphadenectomy complain of GI symptoms during recovery and 2 more cases have been readmitted for the appearance of nausea and vomiting with respect to 3 cases (5%) in the group of only pelvic lymphadenectomies (p=0.00001). According to multivariate analysis, the main determinant of post/operative GI dysfunction is the systematic aortic lymphadenectomy. Twenty-two out of a total of 28 symptomatic patients (78.6%) have accused mild symptoms and have been therefore treated by fasting, by intravenous fluid administration and by anti-emetic drugs. Out of the six remaining patients, three patients (10.7%) have been classified as moderate cases because they have required the insertion of a nasogastric tube for gastric decompression, whereas in the remaining refractory patients (10.7%, severe cases) prokinetics drugs have been used. An exploratory laparotomy has never been performed.

CONCLUSIONS

GI dysfunction symptoms are very common in patients submitted to systematic para-aortic lymphadenectomy. However, only 20% of the patients complain about moderate/severe symptoms. In these cases, we strongly recommend a conservative management.

Alvimopan

Alvimopan is a synthetic peripherally restricted mu-receptor opioid antagonist. Alvimopan has a greater affinity for the mu-receptor than the kappa- or sigma-opioid receptors (Ki = 0.77 nM). The polarity of the molecule limits gastrointestinal absorption and central nervous system penetration. It has limited systemic bioavailability and higher affinity for the mu-opioid receptor than naloxone (Ki = 3.7 nM). Completed Phase III trials suggest efficacy in accelerating the recovery of gastrointestinal function after abdominal surgery. Adverse events with all doses have been similar to placebo groups. Further efficacy in alleviating opioid-induced bowel dysfunction in patients with chronic opioid usage has also been demonstrated. This evidence-based review assesses this new drug and discusses its potential role in clinical practice.