Effect of alvimopan on accelerates gastrointestinal recovery after radical cystectomy: A systematic review and meta-analysis

Advances in Bowel Preparation and Antimicrobial Prophylaxis for Open and Laparoscopic Urologic Surgery

Surgical site infections (SSIs) represent a major source of postoperative complications adversely impacting morbidity and mortality indices in surgical care. The discovery of antibiotics in the mid-20th century, and their ensuing use for preoperative antimicrobial bowel preparation and prophylaxis, drastically reduced the occurrence of SSIs providing a major tool to surgeons of various specialties, including urology. Because, the appropriate use of these antimicrobials is critical for their continued safety and efficacy, an understanding of the recommendations guiding their application is essential for all surgeons. Here, we comprehensively review these recommendations with a focus on open and laparoscopic urologic surgeries.

Use of naldemedine is associated with reduced incidence of hyperactive delirium in cancer patients with opioid-induced constipation: a nationwide retrospective cohort study in Japan

BACKGROUND

Medical benefits of peripherally-acting mu-opioid receptor antagonists other than improving opioid-induced constipation remain unclear. Our aim was to evaluate the association between the use of naldemedine and incidence of hyperactive delirium in cancer patients receiving chemotherapy and opioid therapy.

METHODS

We conducted a propensity score-matched analysis using a nationwide inpatient database in Japan. Cancer patients receiving both inpatient chemotherapy and opioid therapy from June 1, 2017 to March 31, 2018 were included. Patients receiving naldemedine were matched to control patients by propensity score. Our primary outcome was the incidence of hyperactive delirium during hospitalization, and secondary outcomes were the length of hospital stay, hospital costs, in-hospital mortality, and incidence of ileus.

RESULTS

Of 34,031 patients receiving inpatient chemotherapy and opioid therapy, 1905 (5.6%) were included in the naldemedine group. After one-to-four propensity score matching, 1904 patients were included in the naldemedine group and 7616 in the control group. Naldemedine users had significantly reduced incidence of hyperactive delirium compared with the control patients (19.4% vs 23.3%; risk difference, -3.9 [95% confidence interval, -5.9 - -1.9]; risk ratio, 0.83 [0.75-0.92]; P<0.001; subdistribution hazard ratio, 0.85 [0.75-0.97]; P=0.015). The median length of hospital stay was significantly shorter in the naldemedine group compared with the control group (12 days [interquartile range, 6-23] vs 14 days [6-26]; P=0.001). The median hospital costs were also significantly lower in the naldemedine group compared with the control group (US $6179 [3351-10,026] vs US $6576 [3436-11,107]; P<0.001). No significant differences were found for in-hospital mortality or incidence of ileus between the groups.

CONCLUSIONS

Our findings suggest that the use of naldemedine may have benefits in preventing hyperactive delirium, shortening hospital stay, and decreasing hospital costs in cancer patients receiving chemotherapy and opioid therapy.

Enhanced Recovery after Surgery for Radical Cystectomy Decreases Postoperative Complications at Different Times

INTRODUCTION

This study aimed to assess whether enhanced recovery after surgery (ERAS) improves, at different time points, postoperative complications in patients undergoing radical cystectomy.

METHODS

We performed a retrospective monocentric study using prospectively maintained databases including all patients treated by radical cystectomy between January 2015 and July 2019. An ERAS protocol was applied in all patients from February 2018. We analyzed and compared between non-ERAS and ERAS groups early and 90-day postoperative complications and 90-day readmission. ERAS was analyzed to know its implication in fast recovery improvement over time.

RESULTS

A total of 150 patients underwent radical cystectomy, 74 without ERAS and 76 with ERAS protocol. ERAS decreased significantly early (p = 0.039) and 90-day (0.012) postoperative complications. In multivariate analysis, ERAS was an independent factor associated with less early (OR: 0.48, 95% CI: 0.25-0.96; p = 0.37) and 90-day (OR: 0.31, 95% CI: 0.14-0.68; p = 0.004) postoperative complications. There was no significant difference between groups for 90-day readmission (p = 0.349). Mean length of stay did not differ significantly between ERAS and non-ERAS groups (12.7 ± 6.2 and 13.1 ± 5.7 days, respectively; p = 0.743).

DISCUSSION/CONCLUSION

Our study shows that ERAS has an early positive impact that lasts over time on postoperative complications. ERAS implementation has decreased early and 90-day postoperative complications without increasing 90-day readmission. In our cohort, length of stay was not improved with ERAS protocol.

Alvimopan as part of the Enhanced Recovery After Surgery protocol following radical cystectomy is associated with decreased hospital stay

OBJECTIVE

To study the effect of alvimopan and the Enhanced Recovery After Surgery protocol on length of hospital stay in patients undergoing radical cystectomy.

METHODS

Our retrospective study involved 296 consecutive patients undergoing radical cystectomy for bladder cancer at our institution from 2010 through 2018. Patients were grouped according to three stages of the Enhanced Recovery After Surgery protocol implementation: (i) pre-Enhanced Recovery After Surgery (group A; n = 146); (ii) pre-alvimopan Enhanced Recovery After Surgery (group B; n = 102); and (iii) Enhanced Recovery After Surgery plus alvimopan (group C; n = 48). The primary outcome was the length of hospital stay. Secondary outcomes were time to first bowel movement, time to tolerate a regular diet, the incidence of postoperative ileus, postoperative complications and 30-day readmission rate.

RESULTS

Group C showed a significantly shorter median length of hospital stay (7 days, P = 0.003), shorter gastrointestinal recovery time (4 days, P = 0.018) and a lower rate of postoperative ileus (14.6%, P = 0.005). The reduction in length of hospital stay, gastrointestinal recovery time and a lower rate of postoperative ileus was significant after controlling for other confounders on multivariable regression analysis. With the open approach, group C showed a significantly shorter length of hospital stay and gastrointestinal recovery time (P = 0.005, P = 0.001, respectively); however, in robotic cohorts, no significant differences were observed. There was no difference among groups in the 30-day readmission rate or postoperative complications.

CONCLUSIONS

Patients undergoing radical cystectomy and managed by an Enhanced Recovery After Surgery protocol experience a significantly shorter length of hospital stay when receiving alvimopan as part of the protocol. Patients seem to derive the optimum benefits of alvimopan when it is used with an open approach; however, these benefits become less obvious with the robotic approach.

Clinical efficacy and safety of enhanced recovery after surgery for patients treated with radical cystectomy and ileal urinary diversion: a systematic review and meta-analysis of randomized controlled trials

The aim of this study was to evaluate the effect of enhanced recovery after surgery (ERAS) on perioperative outcomes in patients undergoing radical cystectomy (RC) and ileal urinary diversion (IUD). We performed a literature search of PubMed, Web of Science, EMBASE, the Cochrane Library and three main Chinese databases (WANFANG, CNKI and VIP) in December 2019 without language restrictions. Two reviewers independently selected studies, evaluated methodological quality and extracted data using Cochrane Collaboration’s tools. Efficacy was assessed by the time to first flatus, first bowel movement, and hospitalization time. Safety was assessed by 30-day readmission and complications after surgery. Our searches identified 6 studies, including 628 patients. A total of 323 (51%) patients took ERAS. We observed that ERAS reduced the time to first flatus [standard mean difference (SMD): −1.65, 95% CI: −2.63 to −0.68, P=0.0009], first bowel movement (SMD: −1.14, 95% CI: −1.78 to −0.50, P=0.0005), and hospitalization time (MD: −4.09, 95% CI: −6.34 to −1.85, P=0.0004). We did not detect significant difference in terms of 30-day readmission [relative risk (RR): 1.33, 95% CI: 0.61–2.88, P=0.48] and postoperative complications (RR: 0.91, 95% CI: 0.65–1.26, P=0.56) between ERAS and conventional recovery after surgery (CRAS). Our findings indicated that ERAS protocols throughout the perioperative period of RC with IUD might reduce hospitalization expenses and contribute to higher turnover ward, more efficient utilization of medical resources and lower risk of nosocomial infection as a result of shorter length of stay. Besides, early rehabilitation of gastrointestinal function might not only facilitate wound healing and early mobilization, thereby reducing the incidence of basic complications such as cardiopulmonary disease, but also improve patients’ psychological trauma and stress response, increase self-confidence and motivation in treatments, and then lead to unexpected benefits. Further large volume, multicenter randomized controlled studies are warranted before making the final clinical guidelines.

Metabolomics Analysis of Laparoscopic Surgery Combined with Wuda Granule to Promote Rapid Recovery of Patients with Colorectal Cancer Using UPLC/Q-TOF-MS/MS

Surgery is the primary curative treatment for patients with nonmetastasized colorectal cancer (CRC). Rate of complications, morbidity, mortality, and overall survival of patients with CRC are factors associated with speed of recovery following surgery. Wuda granule (WD) is a traditional Chinese medicine (TCM) prescription used to promote rapid recovery after surgery. However, the specific mechanism of action of WD has not been characterized. Our study included 60 patients with clear histopathological evidence of colon or rectal cancer who underwent CRC laparoscopic surgery and 30 healthy individuals. Serum biochemistry and clinical evaluation of gastrointestinal function showed that WD could improve the nutritional status and gastrointestinal function and reduce the level of inflammation of patients with CRC following laparoscopic surgery. In addition, we used UPLC/Q-TOF-MS/MS-based metabolomics analysis to determine the mechanism of WD-related rapid recovery following laparoscopic surgery in patients with CRC. Twenty metabolites associated with arachidonic acid, alanine, aspartate and glutamate, α-linolenic acid, pyruvate, histidine, and glycerophospholipids were identified. The results suggested that the therapeutic mechanism of laparoscopic surgery combined with WD may be related to regulation of nutritional status, inflammation, immune function, energy, and gastrointestinal function in patients with CRC. This study also highlighted the ability of TCM compounds to interact with multiple targets to induce synergistic effects. This study may result in further studies of WD as a therapeutic agent to promote recovery following surgical resection of CRC tumors.

A Retrospective Study of Patients Undergoing Radical Cystectomy and Receiving Peri-Operative Naloxegol or Alvimopan: Comparison of Length of Stay

Alvimopan is a μ-opioid receptor antagonist used in the post-operative period to decrease rates of post-operative ileus (POI) following radical cystectomy (RC) and thereby shorten length of stay (LOS). Naloxegol is a much less expensive drug of the same class that has yet to be studied for prevention of POI in the peri-operative period. The purpose of the current study is to evaluate the differences in LOS and development of POI in patients post-RC who take alvimopan versus those who take naloxegol, with the hope that drug efficacy can be evaluated against the significant difference in cost burden between the two drugs. The study population included all adult patients between 18-89 years of age with bladder cancer undergoing radical cystectomy with urostomy at University of Colorado Hospital. Those patients who received usual post-operative care as well as either alvimopan or naloxegol between September 2011 and December 2017 were selected for analysis. Patients who did not take either medication or were switched from one drug to the other were excluded from the study. A zero-truncated binomial regression analysis was used to analyze differences in length of stay in patients who received alvimopan versus those who received naloxegol. Additionally, the incidence of post-operative ileus was compared between treatment groups. 130 patients who underwent RC and received either alvimopan or naloxegol were included in the study: 75 (58%) received alvimopan and 55 (42%) received naloxegol. Baseline characteristics were similar between treatment groups. There was no significant difference in the length of stay between patients who received alvimopan and patients who received naloxegol after adjusting for age, sex, BMI, length of surgical time, or stage of disease (p = 0.41). There was no significant between the two drugs for development of POI (p = 0.85). Development of POI was significantly associated with a longer LOS (p = 0.007). The analysis showed that naloxegol was comparable to alvimopan when it came to length of hospital stay following RC. Therefore, naloxegol may be offered as a less expensive, effective alternative to alvimopan.

Enhanced Recovery After Surgery Pathways: Role and Outcomes in the Management of Muscle Invasive Bladder Cancer

Radical cystectomy remains the gold standard therapy for the treatment of muscle-invasive urothelial carcinoma, yet is accompanied by significant rates of perioperative complications and readmission. Enhanced recovery protocols aim to apply evidence-based principles of care to ameliorate the morbidity of this procedure by enabling better tolerance of and recovery from radical cystectomy. Multiple patient series have demonstrated the capacity for enhanced-recovery-after-surgery (ERAS) principles to improve outcomes among patients undergoing radical cystectomy through decreased incidence of gastrointestinal complications and decreased length of hospitalization without increased readmissions or overall morbidity. Opportunities remain for adoption of established ERAS principles.

A prospective randomized pilot study evaluating an ERAS protocol versus a standard protocol for patients treated with radical cystectomy and urinary diversion for bladder cancer

PURPOSE

There is a lack of evidence demonstrating the benefits of using enhanced recovery after surgery protocols (ERAS). Here, we propose to use a randomized clinical pilot study to demonstrate the benefits and feasibility of implementing ERAS versus standard protocols (SP) in patients undergoing radical cystectomy (RC) and urinary diversion.

METHODS

27 consecutive patients undergoing RC were included in the study. 12 patients were prospectively randomized to follow an ERAS protocol and 15 patients followed an SP. Duration of hospital stay, time to first flatulence and bowel movement, complications and 30 day readmission rates, as well as subjective outcomes such as postoperative pain, nausea, bowel symptoms, quality of life (QoL), and patient experience and satisfaction were evaluated.

RESULTS

Patients following ERAS had a significantly shorter: hospital stay, time to flatulence, and time to bowel movement than patients following SP. No major complications were reported. Only one patient in the ERAS group was readmitted for bowel obstruction, and no patients were readmitted in the SP group. Patients under ERAS reported lower postoperative pain scores. Mean Functional Assessment of Cancer Therapy Bladder Cancer score decreased and mean Expanded Prostate Cancer Index Composite, bowel symptom score increased in the SP group at the time of discharge compared to prior to surgery.

CONCLUSIONS

This study shows the feasibility of a randomized pilot study assessing ERAS compared to SP post RC. ERAS protocol provided evidence of significant benefits over SP with similar complication rates. This study suggests the need for a clinical trial of assessing ERAS protocols after RC.

Alvimopan for recovery of bowel function after radical cystectomy

BACKGROUND

Alvimopan is used in abdominal surgery to reduce postoperative ileus in patients undergoing small bowel resections with primary anastomosis. The role and efficacy of alvimopan in patients undergoing radical cystectomy with urinary diversion is not well understood.

OBJECTIVES

To assess the effects of alvimopan in the context of enhanced recovery pathways compared to enhanced recovery pathways alone for perioperative bowel dysfunction in patients undergoing radical cystectomy.

SEARCH METHODS

The terms alvimopan and cystectomy were used to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. We also reviewed abstracts from the past four years (2013 to 2016) of the American Urologic Association, Society of Urologic Oncology, and American Society of Clinical Oncology Genitourinary Cancers.

SELECTION CRITERIA

We searched for randomized controlled trials that compared alvimopan to placebo.

DATA COLLECTION AND ANALYSIS

This study was based on a published protocol. We performed a comprehensive search of multiple databases including CENTRAL in the Cochrane Library, MEDLINE, Embase, LILACS, Web of Science, Scopus and Biosis, which we last updated on 6 February 2017. We also searched abstract proceedings for major relevant meetings (2013 to 2016), databases of the grey literature, trial registries, citations of relevant reviews and contacted clinical experts and the drug manufacturer.Two independent reviewers screened the literature in two stages (title and abstract, full-text) using Covidence software. Two independent reviewers assessed the risk of bias on a 'per outcome' basis using the Cochrane 'Risk of bias; tool and rated the quality of evidence according to GRADE. Results of the single eligible trial were reported in a 'Summary of findings' table based on an intention-to-treat analysis.

MAIN RESULTS

Based on a single trial and moderate-quality evidence, alvimopan reduced the time to reach a composite endpoint of tolerance of solid food and documented bowel movements (hazard ratio (HR) 1.77, 95% confidence interval (CI) 1.41 to 2.23). This represents 165 more patients (109 more to 207 more) per 1000 meeting this endpoint within 10 days of surgery. Based on moderate-quality evidence, alvimopan reduced the time to hospital discharge (HR 1.67, 95% CI 1.38 to 2.01). This represents 138 more patients (82 more to 198 more) per 1000 being discharged within 10 days of surgery. Also based on moderate-quality evidence, alvimopan was associated with a reduced risk of major adverse events (risk ratio (RR) 0.28, 95% CI 0.18 to 0.44) representing 355 fewer patients (404 fewer to 276 fewer) with major adverse events per 1000. We downgraded this outcome for indirectness as it included adverse events that we did not consider major.In terms of secondary outcomes, alvimopan did not appear to alter the rate of readmission (RR 0.89, 95% CI 0.59 to 1.33), change the rate of any cardiovascular event (RR 0.54, 95% CI 0.27 to 1.05) or alter the mean narcotic pain medication use (mean difference 0, 95% CI 14.08 fewer to 14.08 more morphine equivalents). The quality of evidence was moderate for all three outcomes. Based on high-quality evidence, alvimopan reduced the rate of nasogastric tube replacement (RR 0.31, 95% CI 0.16 to 0.59). We did not find evidence for the drug's impact on rates of parenteral nutrition. All outcomes were short term and limited to a 30-day time horizon.Based on the existence of only one trial, we were unable to perform any subgroup or sensitivity analyses.

AUTHORS' CONCLUSIONS

In patients undergoing radical cystectomy and urinary diversion, the use of alvimopan administered as part of an enhanced recovery pathway for a limited duration (up to 15 doses for up to seven days) probably reduces the time to tolerance of solid food, time to hospital discharge and rates of major adverse events. Readmission rates, rates of cardiovascular events and narcotic pain requirements are probably similar. The need for reinsertion of nasogastric tubes is reduced. We found no evidence for the impact on rates of parenteral nutrition within 30 postoperative days.

How to lower postoperative complications after radical cystectomy - a review

Introduction

Lowering morbidity and mortality after RC is subject of considerable interest. Lately, many evidence-based data on improvements in operative technique, anesthetic management, and patient care have been published.

In this article, we present a review of literature on how to lower postoperative complications after RC.

Material and methods

The Medline, and Web of Science databases were searched without a time limit on February 2016 using the terms ‘cystectomy’ in conjunction with ‘radical’, ‘bladder cancer’, ‘complications’ or ‘management’. Boolean operators (NOT, AND, OR) were also used in succession to narrow and broaden the search. The search was limited to the English, Polish and Spanish literature.

Results

Many complications may be avoided by appropriate patient selection and meticulous introduction of care protocols.

Conclusions

RC as treatment free of complications, even in the hands of an experienced urologist, does not exist. A large number of complications are acceptable in the name of good long-term results. Optimum results are possible with proper surgical technique, good patients and urinary diversion selection and proper patient management in the pre-, peri, and postoperative period.