Alvimopan in the setting of colorectal resection with an ostomy: To use or not to use?

Abstract

Postoperative ileus (POI) is a major cause of morbidity, increased length of stay (LOS) and hospital cost after colorectal surgery. Alvimopan is a µ-opioid antagonist used to accelerate upper and lower gastrointestinal function after bowel resection. We hypothesized that alvimopan would reduce LOS in patients undergoing colorectal resection with stoma, a situation that has not been evaluated. A retrospective review (2010-2015) identified 58 patients who underwent colorectal resection for benign or malignant disease with stoma creation and received alvimopan. They were case-matched to 58 non-alvimopan patients based on age, BMI, baseline comorbidities, stoma type created and surgical approach. We compared overall LOS, incidence of POI and other postoperative complications. There were equal numbers of laparoscopic (N=18) and open resections (N=40) in the alvimopan group and non-alvimopan group. There were also equal numbers of patients with an ileostomy (N=37) or colostomy (N=21) in each group. Overall, 41 patients underwent resection for malignant disease in the alvimopan group compared to 37 in the non-alvimopan group. There was a significant reduction in median LOS overall (alvimopan 5 (4-7) versus control 6 (4.75-9.25) days, P=0.03). While the 6-day median LOS was similar for patients undergoing ileostomy creation (P=0.25), alvimopan patients had a 3-day decreased median LOS that approached statistical significance (P=0.06). The overall 30-day complication rate was higher in the control group (41.4 vs. 51.7%, P=0.26), but the readmission rate within 30days was higher in the alvimopan group (19 vs. 13.8%, P=0.45). Neither of these differences reached statistically significance. The use of alvimopan in patients undergoing colorectal resection with stoma is associated with a significantly shorter LOS, but the increased readmission rate warrants further study. Based on these data, alvimopan should be evaluated in a controlled setting for patients undergoing colorectal resection with colostomy creation.