Preventive Measures to Minimize or Avoid Postoperative Ileus

Risk factors associated with prolonged postoperative ileus after elective colon resection

BACKGROUND

There is a coordinated inhibition of motility of the colon after its surgical manipulation that contributes to the accumulation of fluids and gas, in turn characterized by nausea,vomiting, pain, abdominal distension, and constipation. Motility is recovered in the majority of patients within the first 72 hours. A delay in its resolution is known as prolonged postoperative ileus.

AIMS

To study the preoperative, intraoperative, and postoperative risk factors for developing prolonged ileus in patients that underwent elective colon resection.Materials and methods: The association between 25 perioperative variables and the presentation of prolonged ileus was analyzed in 85 patients that underwent colon resection at Hospital Christus Muguerza Alta Especialidad within the time frame of 2011 and 2014.

RESULTS

Postoperative ileus occurred in 22.3% of the patients. The statistically significant predictors of ileus were obesity (OR 1.119, P=.048) and admission to the intensive care unit (OR3.571, P=.050). The use of peridural anesthesia during the surgical act was found to be a protective factor (OR 0.363, P=.050).

CONCLUSIONS

The presence of these risk factors can alert the physician to the need for a closer follow-up in patients at high risk for postoperative ileus, and the use of peridural anesthesiacan possibly lower the incidence of ileus.

"Ultra" E.R.A.S. in laparoscopic colectomy for cancer: discharge after the first flatus? A prospective, randomized trial

BACKGROUND

Enhanced Recovery After Surgery (E.R.A.S.) programs are now widely accepted in colonic laparoscopic resections because of faster recovery and less perioperative complications. The aim of this study was to assess safety and feasibility of discharging patients operated on by laparoscopic colectomy on postoperative day 2, so long as the first flatus has passed and in the absence of complication-related symptoms.

METHODS

This study was a non-inferiority, open-label, single-center, prospective, randomized study comparing "Ultra" to Classic E.R.A.S. with discharge on POD 2 and 4, respectively. Seven hundred and sixty-five patients with resectable non-metastatic colonic cancer were analyzed: 384 patients were assigned to "Ultra" E.R.A.S. and 381 to Classic E.R.A.S. Primary end-point was mortality; secondary end-points were morbidity, readmission and reoperation rate. Limitations are: it is a single-center experience; it is not double-blind, with the intrinsic risk of intentional or unconscious bias; exclusion criteria because of "non-compliance" may be considered arbitrary.

RESULTS

Mortality was 0.89 % in "Ultra" E.R.A.S. group and 0.59 % in Classic E.R.A.S. (p = 0.571). Morbidity was 34.1 % for "Ultra" E.R.A.S. arm and 35.4 % for Classic E.R.A.S. (p = 0.753). Readmissions were 5.6 % for "Ultra" E.R.A.S. and 5.9 % for Classic E.R.A.S. (p = 0.359). Reoperation rate was 3.8 % for "Ultra" ERAS and 4.7 % for Classic E.R.A.S. (p = 0.713). Multivariate regression analyses using Cox's proportional hazard model showed that mortality (primary end-point), morbidity, reoperation and readmission (secondary end-points) were not significantly influenced by the two different perioperative regimens; conversely, the global cost of "Ultra" E.R.A.S. regimen was more economically effective.

CONCLUSION

"Ultra" E.R.A.S. showed to be safe, actual and effective; discharge on postoperative day 2 after the first flatus passage, in the absence of complication-related symptoms, should be actively considered in a modern, multidisciplinary, multimodal laparoscopic management of colonic cancer.

Alvimopan use in laparoscopic and open bowel resections: clinical results in a large community hospital system

BACKGROUND

Alvimopan has received Food and Drug Administration approval to accelerate the time to upper and lower gastrointestinal recovery following partial large or small bowel resection with primary anastomosis.

OBJECTIVE

To assess the efficacy, safety, and economic benefit of alvimopan in patients undergoing open or laparoscopic bowel resection in a community hospital system setting.

METHODS

This 6-month, open-label, multi-hospital, prospective study combined with a retrospective chart review compared postoperative length of stay and postoperative ileus-related morbidity (nasogastric tube insertion, hospital readmission) for patients undergoing open or laparoscopic bowel resection who received alvimopan 12 mg (n = 108) versus historical control bowel resection patients (n = 91) who would have been eligible to receive alvimopan. Multivariate analysis assessed the effects of age and surgery type on postoperative length of stay. Additional-day hospital costs were estimated using ordinary least-squares regression to calculate costs based on length of stay in the control cohort.

RESULTS

Compared with historical controls, patients receiving alvimopan had a mean 1.8-day shorter postoperative length of stay (p = 0.01) and lower rates of nasogastric tube insertion (2% vs 15%, p < 0.001). Multivariate analysis revealed a statistically significant reduction in postoperative length of stay in the alvimopan group of approximately 1.2 days (p = 0.01), regardless of age or surgery type, with an even larger difference (3.2 days) observed in patients ≥70 years old. Mean cost savings associated with alvimopan use ranged from $531 (laparoscopic bowel resection) to $997 (open bowel resection) per patient.

CONCLUSIONS

Consistent with clinical trial data, alvimopan use resulted in an approximately 1 day shorter postoperative length of stay and was associated with substantial cost savings.

Critical pathway for patients undergoing aortic-surgery: Impact on postoperative care at an intensive care unit in Sweden

In January 2007, the intensive care unit (ICU) at a Swedish hospital introduced a critical pathway for patients undergoing aortic-surgery. The aim of this study is to evaluate the impact of this initiative, with regard to postoperative care in an ICU. A comparison of two patient groups - 17 patients treated one year before and 20 patients treated one year after the introduction of the pathway - was performed, and considered nasogastric tube, intake of clear fluids, intake of nutrition drink or meal, breathing exercise and mobilization. No statistically significant differences in mean age, gender, anaesthetic risk factors, peroperative bleeding, length of surgery and length of mechanic ventilation between the groups existed. The patients in the pathway group had their nasogastric tube removed significantly earlier (P < 0.05) and received intake of clear fluids and nutrition drink or meal significantly (P < 0.05) earlier than patients in the control group. Critical pathway for patients undergoing aortic-surgery has a positive impact on postoperative care. Aortic-surgery patients treated in accordance with the pathway at the ICU received nursing interventions earlier than patients who were treated without pathway, which is crucial for the quality of care and optimal outcome.

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.

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.

Evidence-based surgical care and the evolution of fast-track surgery

BACKGROUND

Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program.

OBJECTIVE

To assess, synthesize, and discuss implementation of "fast-track" recovery programs.

DATA SOURCES

Medline MBASE (January 1966-May 2007) and the Cochrane library (January 1966-May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work.

DATA SYNTHESIS

Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the "fast-track methodology" has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered "surgery-specific" morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology.

CONCLUSION

Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.

Effect of laxatives on gastrointestinal functional recovery in fast-track hysterectomy: a double-blind, placebo-controlled randomized study

OBJECTIVE

The purpose of this study was to determine the effect of early oral bowel stimulation with osmotic laxatives on gastrointestinal function, postoperative nausea and vomiting (PONV) and pain in patients who undergo fast-track abdominal hysterectomy.

STUDY DESIGN

This was a double-blind, placebo-controlled study of 53 women who were assigned randomly to either laxative (magnesium oxide + disodium phosphate) or placebo that was initiated 6 hours after the operation. Primary outcome was time to first defecation; the number of vomiting episodes; nausea and pain score were assessed on a visual analogue scale.

RESULTS

Time to first postoperative defecation was a median of 45 hours in the laxative group and a median of 69 hours in the placebo group (P < .0001). There were no significant differences between groups in pain scores, PONV and the use of morphine or antiemetics. Postoperative hospitalization was a median of 1 day in the laxative group and of 2 days in the placebo group (P = .41).

CONCLUSION

Laxative improves recovery of gastrointestinal function after fast-track hysterectomy but has no significant effect on pain and PONV.

Future perspectives and research initiatives in fast-track surgery

BACKGROUND AND AIMS

Major surgery is still followed by a risk of morbidity, a need for hospitalisation and convalescence. Fast-track surgery has been introduced as a coordinated effort to combine unimodal evidence-based principles of care into a multi-modal effort to enhance recovery. The aim of this article was to update recent data on fast-track abdominal surgery and outline future strategies for research.

RESULTS

The data from fast-track colonic resection support the validity of the concept because pain, ileus, cardiopulmonary function and muscle function were all improved, compared with traditional treatment and with reduced post-operative fatigue and convalescence. Although less data is available, similar positive results may be achieved in other types of major surgery. Current research initiatives include improved multi-modal non-opioid analgesia, rational principles for perioperative fluid management, pharmacological reduction of surgical stress responses and the role of laparoscopic procedures within the fast-track concept.

CONCLUSIONS

Fast-track surgery has evolved as a valid concept to improve post-operative outcome. Further progress may be expected based upon intensified research within perioperative pathophysiology and a multi-disciplinary collaboration between surgeons, anaesthesiologists and surgical nurses.