Bowel Function In Patients Research Articles

Attempted bladder reinnervation and creation of a scratch reflex for bladder emptying through a somatic-to-autonomic intradural anastomosis

An intradural somatic-to-autonomic anastomosis, or Xiao procedure, has been described to create a "skin-CNS-bladder" reflex that improves bladder and bowel function in patients with neurogenic bladder and bowel dysfunction. The authors present their experience with a 10-year-old boy with chronic neurogenic bladder and bowel dysfunction related to spinal cord injury who underwent the Xiao procedure. After undergoing a left L-5 ventral root to left S2-3 intradural anastomosis, the patient reported that his bladder and bowel dysfunction improved between 6 and 12 months. Two years after the procedure, however, he reported that there was no change in his bladder or bowel dysfunction as compared with his condition prior to the procedure. Frequent, systematic multidisciplinary evaluations produced conflicting data. Electrophysiological and histological evaluation of the previously performed anastomosis during surgical reexploration 3 years after the Xiao procedure revealed that the anastomosis was in anatomical continuity but neuroma formation had prevented reinnervation. Nerve action potentials were not demonstrable across the anastomosis, and stimulation of the nerve above and below the anastomosis created no bladder or perineal contractions. This is the first clinical report on the outcome of the Xiao procedure in a child with spinal cord injury outside of China. It is impossible to draw broad conclusions about the efficacy of the procedure based on a single patient with no demonstrable benefit. However, future studies should carefully interpret transient improvements in bladder function, urodynamic findings, and the patient's ability to void in response to scratching after the Xiao procedure. The authors' experience with the featured patient, in whom reinnervation could not be demonstrated, suggests that such changes could be related to factors other than the establishment of a skin-CNS-bladder reflex as a result of a somatic-to-autonomic anastomosis.

Effects of Manual Therapy on Bowel Function of Patients with Spinal Cord Injury

[Purpose] The purpose of this study was to observe the effects of manual therapy on bowel function of patients with spinal cord injury. [Subjects] The participants were 20 patients with spinal cord injury. [Methods] Manual therapy was applied to the intestine and along the colon ascendens, transverse colon, colon descendens and colon sigmoidem on the surface of abdomen. The results before and after 60 sessions (5 times/week, continued for 12 weeks) of manual therapy were compared. [Results] It was found that there were significant effects both on shortening of bowel time and decreasing dosage of glycerine enema every time patients needed to excrete. [Conclusion] Manual therapy had significant effects on bowel function of patients with spinal cord injury.

Electroacupuncture Improves Bladder and Bowel Function in Patients with Traumatic Spinal Cord Injury: Results from a Prospective Observational Study

In order to explore the effect of electroacupuncture (EA) for chronic bowel and bladder dysfunction after traumatic spinal cord injury, 14 patients were treated with electroacupuncture once a day, five times a week for the first four weeks, and once every other day, three times a week for the following four weeks. The patients were then followed up for six months. After treatment, four (4/14, 28.57%) patients resumed normal voiding; six (6/14, 42.86%) resumed normal voiding for no less than half of all micturition behaviors; four (4/14, 28.57%) required supplementary urination methods for higher than half of all micturition behaviors. These effects persisted during followup. Mean postvoid RUV decreased by 190.29 ± 101.87 mL (P < 0.01) after treatment and by 198.86 ± 112.18 mL (P < 0.01) during followup. Patients' weekly urinary incontinence frequency decreased 7.14 ± 46.34 times/week (P = 0.036) after treatment and decreased 49.86 ± 44.38 times/week during followup. After treatment, four (4/14, 28.57%) patients resumed normal bowel movements (P = 0.025); five (5/14, 35.71%) reduced the dependence on supplementary defecation methods; five (5/14, 35.71%) had no changes. In patients with chronic bowel and bladder dysfunction after traumatic SCI, EA may provide a valuable alternative tool in improving patients' self-controlled bowel and bladder functions with minimal side effects.

Chewing gums has stimulatory effects on bowel function in patients undergoing cesarean section: A randomized controlled trial

The aim of study was to investigate the effect of postoperative gum chewing on the recovery of bowel function after cesarean section. Total 100 women delivered by lower uterine segment section cesarean under local anesthesia (spinal). Eligible patients were randomly allocated into two groups: a gum-chewing group (n=50) or a control group (n= 50). The gum-chewing group participants who received one stick of sugarless gum for one hours, three times daily immediately after recovery from anesthesia and the control group had the usual postoperative care until being discharged. All women were followed up regularly until discharge from hospital, and recorded the times to the first bowel sounds of normal intestinal sounds, the time to the first passage of flatus, the time to the first feeling of hunger, and the time to the first defecation. The operative data, postoperative tolerance of gum chewing, and postoperative complications were documented. There was no statistically significant difference between the two groups in terms of demographic characteristics such as age, body mass index, parity, duration of surgery, number of miscarriages and curettages, time to the first feeding, the amount of serum intake, and type of cesarean section. The mean average postoperative interval of the first bowel sounds (21.9 versus 26.1 hours, p= 0.016), the first feeling of hunger (11.8 versus 14.5 hours, p= 0.050), the first passage of flatus (24.8 versus 30.0 hours, P=0.002), the first defecation (30.6 versus 38.4 hours, P= 0.0001) was significantly shorter compared to the control group.

Sigmoidectomy Syndrome? Patients' Perspectives on the Functional Outcomes Following Surgery for Diverticulitis

Bowel function following surgery for diverticulitis has not previously been systematically described. This study aimed to document the frequency, severity, and predictors of suboptimal bowel function in patients who have undergone sigmoid colectomy for diverticulitis. This study is a retrospective analysis. This study was conducted at a large, academic medical center. Three hundred twenty-five patients who underwent laparoscopic or open sigmoid colectomy with restoration of intestinal continuity for diverticulitis were included in the study population. Of these, 249 patients (76.6%) returned a 70-question survey incorporating the Fecal Incontinence Severity Index, the Fecal Incontinence Quality of Life Scale, and the Memorial Bowel Function Instrument. Survey responders and nonresponders were compared with the use of χ and t tests. Responders with suboptimal bowel function (fecal incontinence, urgency and/or incomplete emptying) were then compared with those with good outcomes by the use of logistic regression analysis to determine the predictors of poor function. Of the responders, 24.8% reported clinically relevant fecal incontinence (Fecal Incontinence Severity Index ≥ 24), 19.6% reported fecal urgency (Memorial Bowel Function Instrument Urgency Subscale ≥ 4), and 20.8% reported incomplete emptying (Memorial Bowel Function Instrument Emptying Subscale ≥ 4). On logistic regression analysis, fecal incontinence was predicted by female sex (OR = 2.3, p = 0.008) and the presence of a preoperative abscess (OR = 1.4, p < 0.05). Fecal urgency was associated with female sex (OR = 1.3, p < 0.05) and a diverting ileostomy (OR = 2.1, p < 0.001). Incomplete emptying was associated with female sex (OR = 1.4, p < 0.05) and postoperative sepsis (OR = 1.9, p < 0.05). This study was limited by the fact that we did not use a nondiverticulitis control group and we had limited preoperative data on the history of bowel impairment symptoms. One-fifth of patients reported fecal urgency, fecal incontinence, or incomplete emptying after surgery for diverticulitis. Despite the limitations of our study, these results are concerning and should be investigated further prospectively.

Better functional outcome provided by short-armed sigmoid colon-rectal side-to-end anastomosis after laparoscopic low anterior resection: a match-paired retrospective study from China

Side-to-end anastomosis using the descending colon has been proved to be as effective as J pouch in alleviating low anterior resection syndrome. However, using the sigmoid colon, which is less compliant for reconstruction after rectal cancer surgery, is common in China due to less prevalence of diverticulosis. The effectiveness of using the sigmoid colon for a side-to-end colorectal anastomosis in improving bowel dysfunction after laparoscopic low anterior resection of rectal cancer has not been investigated. This study was designed to compare the functional and surgical outcomes between the two anastomoses. From October 2007 to December 2008, 16 rectal cancer patients underwent laparoscopic low anterior resection with short-armed (length of side limb 2-4 cm) side-to-end sigmoidorectal anastomosis at our department. The bowel functional results of these patients at 6 months and 1 year postoperatively were recorded and compared with that of another 1:2 matched 30 patients undergoing straight anastomosis. Bowel movement frequency in the side-to-end group was obviously less than that in the straight group 6 months postoperatively. Patients in the side-to-end group also had an improved incontinence score, a better ability to defer defecation, and less repeated evacuation. No differences were found between two groups 1 year after surgery. The study shows that the short-armed side-to-end colorectal anastomosis using the sigmoid colon can also improve the short-term bowel function in patients undergoing laparoscopic low anterior resection.

Intravenous Lidocaine Versus Thoracic Epidural Analgesia

Laparoscopy, thoracic epidural analgesia, and enhanced recovery program (ERP) have been shown to be the major elements to facilitate the postoperative recovery strategy in open colorectal surgery. This study compared the effect of intraoperative and postoperative intravenous (IV) lidocaine infusion with thoracic epidural analgesia on postoperative restoration of bowel function in patients undergoing laparoscopic colorectal resection using an ERP. Sixty patients scheduled for elective laparoscopic colorectal surgery were prospectively randomized to receive either thoracic epidural analgesia (TEA group) or IV lidocaine infusion (IL group) (1 mg/kg per hour) with patient-controlled analgesia morphine for the first 48 hours after surgery. All patients received a similar ERP. The primary outcome was time to return of bowel function. Postoperative pain intensity, time out of bed, dietary intake, duration of hospital stay, and postoperative complications were also recorded. Mean times and SD (95% confidence interval) to first flatus (TEA, 24 [SD, 11] [19-29] hrs vs IL, 27 [SD, 12] [22-32] hrs) and to bowel movements (TEA, 44 ±19 [35-52] hrs vs IL, 43 [SD, 20] [34-51] hrs) were similar in both groups (P = 0.887). Thoracic epidural analgesia provided better analgesia in patients undergoing rectal surgery. Time out of bed and dietary intake were similar. Patients in the TEA and IL groups were discharged on median day 3 (interquartile range, 3-4 days), P = 0.744. Sixty percent of patients in both groups left the hospital on day 3. Intraoperative and postoperative IV infusion of lidocaine in patients undergoing laparoscopic colorectal resection using an ERP had a similar impact on bowel function compared with thoracic epidural analgesia.

1502 THREE-YEAR CLINICAL OUTCOMES WITH LUMBAR TO SACRAL NERVE REROUTING IN SPINA BIFIDA

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Neurogenic Voiding Dysfunction1 Apr 20111502 THREE-YEAR CLINICAL OUTCOMES WITH LUMBAR TO SACRAL NERVE REROUTING IN SPINA BIFIDA Kenneth Peters, Kevin Feber, Benjamin Girdler, William Nantau, Evan Kass, Jose Gonzalez, Gary Trock, and Ananias Diokno Kenneth PetersKenneth Peters Royal Oak, MI More articles by this author , Kevin FeberKevin Feber Royal Oak, MI More articles by this author , Benjamin GirdlerBenjamin Girdler Royal Oak, MI More articles by this author , William NantauWilliam Nantau Royal Oak, MI More articles by this author , Evan KassEvan Kass Royal Oak, MI More articles by this author , Jose GonzalezJose Gonzalez Royal Oak, MI More articles by this author , Gary TrockGary Trock Royal Oak, MI More articles by this author , and Ananias DioknoAnanias Diokno Royal Oak, MI More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1481AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The concept of restoring bladder and bowel function in spina bifida by the creation of a skin-CNS-bladder reflex arc by an intradural lumbar to sacral motor root microanastomosis was introduced by Xiao. We report our three-year experience with the novel procedure. METHODS Nine patients (3 males, 6 females) with median age of 8 (range 6 to 37) years enrolled in this institutional review board approved protocol. After extensive preoperative evaluation, lumbar to sacral nerve rerouting was performed using intraoperative neurophysiological monitoring. Postoperative evaluation included follow-up questionnaires, urodynamic testing (UDT), voiding diaries, renal function studies and bowel assessment. RESULTS Of the 9 patients, 5 patients had defect closure within 24 hours of birth, 3 had intrauterine closure and 1 had no prior surgery. Mean operative time was 183 (range 127–278) minutes. No intraoperative complications occurred. One patient developed permanent foot drop and 8 had transient lower extremity weakness. By 12 months, 7 of 9 had a documented cutaneous to bladder reflex. At 3 years, 2 patients did not return for follow-up and were considered non-responders. Seven patients returned for 36-month evaluation. On UDT, maximum cystometric capacity improved from mean 210 cc to 293 cc. At baseline 4/7 had neurogenic detrusor overactivity (NDO); at 36 months 1/7 had NDO. Median compliance improved from 12.2 ml/H20 to 28.4 ml/H2O and 3 with a baseline compliance of less than 10 had normalization (7 to 34.3, 9.4 to 21.2, and 8.3 to 28.4). At baseline, 2/7 were able to void with an average void of 23 cc. At 36 months, 6/7 no longer required catheterization and 6/7 reported mean voided volume of 156cc on voiding diaries. Uroflow demonstrated a mean voided volume of 248 cc with a 93 cc post void residual and a voiding efficiency of 73%. All 6 patients were voiding > 59% of their bladder capacity. 5 of 7 require some valsalva to void. 6/7 subjects had persistent stress incontinence with 1 subject dry, 3 with occasional leak, 3 frequent leaks. At baseline, 3/7 considered their bowels normal and 1/7 were continent of stool. At 36-months 6/7 considered bowels normal and 4/7 continent of stool. Antimuscarinics were stopped in all subjects except the 1 with persistent NDO. Renal ultrasounds and serum creatinines remained stable. No long-term complications were identified and 6/7 would undergo the procedure again. CONCLUSIONS Lumbar to sacral nerve rerouting can improve bladder and bowel function in patients with neurogenic bladder associated with spina bifida. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited ByRasmussen M, Rawashdeh Y, Clemmensen D, Tankisi H, Fuglsang-Frederiksen A, Krogh K and Christensen P (2018) The Artificial Somato-Autonomic Reflex Arch Does Not Improve Lower Urinary Tract Function in Patients with Spinal Cord LesionsJournal of Urology, VOL. 193, NO. 2, (598-604), Online publication date: 1-Feb-2015. Volume 185Issue 4SApril 2011Page: e602 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kenneth Peters Royal Oak, MI More articles by this author Kevin Feber Royal Oak, MI More articles by this author Benjamin Girdler Royal Oak, MI More articles by this author William Nantau Royal Oak, MI More articles by this author Evan Kass Royal Oak, MI More articles by this author Jose Gonzalez Royal Oak, MI More articles by this author Gary Trock Royal Oak, MI More articles by this author Ananias Diokno Royal Oak, MI More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Enhancing Oral Bioavailability of Methylnaltrexone Using an Emulsion Formulation

Methylnaltrexone (MNTX) is a peripherally-acting opioid receptor antagonist. Since it has restricted access to the blood-brain barrier, MNTX has the ability to decrease opioid-induced constipation without affecting the analgesic effects of opioid pain medications. MNTX has a limited gastrointestinal absorption and currently, only subcutaneous MNTX is clinically available to help restore bowel function in patients with late-stage advanced illness who are receiving opioids. A MNTX emulsion (MNTX-EM) formulation was prepared in this study to improve the oral bioavailability of the compound. A sensitive liquid chromatography-tandem mass spectrometry (LC/MS/MS) method was established and validated for the determination of MNTX plasma concentrations. With an extended linear range of 1 to 1000 ng/mL, this assay was specific, precise, and accurate. Following 110 mg/kg oral administrations of unformulated methylnaltrexone water solution (MNTX-WS) and MNTX-EM in rats, plasma samples were collected for up to 9 h and MNTX levels were measured. The plasma MNTX concentrations after MNTX-WS and MNTX-EM were compared. Data showed that there were two MNTX concentration peaks after both MNTX-WS and MNTX-EM. For the first peak, the peak plasma concentration (Cmax) and the area under the concentration curve (AUC) from 0 to 60 min for MNTX-WS and MNTX-EM were 210.0 ng/mL, 87.2 ng • h/mL and 390.2 ng/mL, 321.9 ng • h/mL, respectively (both P < 0.01). For the second peak, Cmax and AUC from 60 to 420 min for MNTX-WS and MNTX-EM were 172.7 ng/mL, 663.4 ng • h/mL and 597.6 ng/mL, 1941.7 ng • h/mL, respectively (both P < 0.01). The relative bioavailability after oral administration of MNTX-EM was 302% compared to that of MNTX-WS. These results suggested that the emulsion formulation might be clinically useful in enhancing the oral absorption of MNTX. Keywords: Methylnaltrexone, Formulation, Emulsion, Oral bioavailability, Liquid chromatography-mass spectrometry, LC/MS/MS, blood-brain barrier, MNTX-WS, Cmax, AUC, Opioid medications, constipation, pain, malignancy, antagonist, Relistor, Labrasol, distilled water, HPLC, plasma, LOD, LOQ, ANOVA, ESI, RSD, bioavailability, chromatogram, lipophilicity, viscosity, absorption

Kiwifruit improves bowel function in patients with irritable bowel syndrome with constipation.

Irritable bowel syndrome (IBS) is a common functional disorder of the gastrointestinal system, and is characterized by abdominal pain, diarrhea (IBS/D), constipation (IBS/C), and alternating diarrhea and constipation (IBSC/A). The purpose of this study was to examine the impact of a four week kiwifruit intervention on bowel function in patients diagnosed with IBS/C. Fifty-four patients with IBS/C and 16 healthy adults participated in this study. All subjects participated in the 6 week, three phase study, which included a baseline phase (1 week), a dietary intervention period (4 weeks), and a post-intervention phase (1 week). Forty-one IBS/C patients and all healthy adults consumed two Hayward green (Actinida deliciosa var) kiwifruits per day for 4 weeks. Thirteen IBS/C patients in the control group took two placebo capsules per day for 4 weeks. Colon transit time was measured immediately prior to and following the intervention period. All subjects completed daily defecation records. After the 4-week intervention, weekly defecation frequency significantly increased in the IBS/C group of participants who consumed kiwifruit (p<0.05). Colon transit time significantly decreased (p=0.026) in the IBS/C group that consumed kiwi fruit. These findings suggest that kiwifruit consumption for 4 weeks shortens colon transit time, increases defecation frequency, and improves bowel function in adults diagnosed with IBS/C.

Evaluation of long-term bowel function in patients with Hirschsprung’s disease after different radical operations

Evaluation of long-term bowel function in patients with Hirschsprung’s disease after different radical operations

Combined oral prolonged-release oxycodone and naloxone in opioid-induced bowel dysfunction: review of efficacy and safety data in the treatment of patients experiencing chronic pain

Importance of the field: Despite proven analgesic efficacy, opioid use is associated with frequently dose-limiting bowel dysfunction that seriously impacts patients' quality of life (QoL). Agents used at present to manage opioid-induced constipation do not address the underlying opioid receptor-mediated cause of bowel dysfunction and are often ineffective. There is, therefore, a significant need for more effective treatment options. The combination of the strong opioid oxycodone and the opioid antagonist naloxone has the potential to prevent opioid-induced bowel dysfunction (OIBD) while maintaining analgesic efficacy.Objective: To review the safety and efficacy of oral prolonged-release (PR) oxycodone/naloxone in the treatment of patients experiencing chronic pain.Areas covered in this review: A MEDLINE search was done (January 2002 – July 2009) for available literature for prolonged release oxycodone and naloxone in different patient groups. Results were limited to English-language and clinical trials. Data were also obtained from congress materials.What knowledge the reader will gain: Unmet needs of opioid pain treatment in terms of OIBD, reduced QoL and low treatment compliance, leading to reduced efficacy. A data overview demonstrates the efficacy and tolerability of PR oxycodone/naloxone in the management of severe chronic pain without the burden of severe gastrointestinal adverse events. The combined formulation of a highly effective opioid and an antagonist that acts locally to reduce gastrointestinal side effects is expected to simplify pain management.Take home message: The combination of PR oxycodone/naloxone offers the potential of maintaining normal bowel function in patients requiring opioid therapy – it is a strong analgesic that is well tolerated.

Long-term outcome of internal sphincter myectomy in patients with internal anal sphincter achalasia

Internal anal sphincter achalasia (IASA) is a condition with presentation similar to Hirschsprung's disease (HD), but with the presence of ganglion cells on rectal suction biopsy (RSB). The diagnosis is made on anorectal manometry (ARM) by the absence of the rectosphincteric reflex on rectal balloon inflation. Internal sphincter myectomy (ISM) is the treatment of choice for patients with IASA. Recently, botulinum toxin has been used to treat IASA patients. The purpose of this study was to assess the long-term bowel function in patients with IASA following ISM. The medical records of 24 patients with IASA managed by ISM during 1993-2005 were examined. There were 18 boys and 6 girls, aged 2-12 years. All patients presented with intractable constipation with or without soiling. The diagnosis was made by the demonstration of the absence of the rectosphincteric reflex on ARM. HD was excluded by the presence of ganglion cells and normal acetylcholinesterase activity in RSB. Patients were followed 4-14 years later. Fifteen (62.5%) patients at the time of follow-up had regular bowel motions without the use of laxatives. Six (25%) patients had regular bowel motions, but remained on small doses of laxatives. Two (8.3%) patients who suffered from constipation and soiling required twice weekly enemas to remain clean. One (4.2%) patient required resection of dilated rectosigmoid colon 3 years after myectomy, remains on laxatives, but has normal bowel control. No patients had faecal incontinence following ISM. This long-term follow-up study shows that the vast majority of IASA patients have normal bowel control following ISM.

Health-related quality of life, faecal continence and bowel function in rectal cancer patients after chemoradiotherapy followed by radical surgery

To evaluate health-related quality of life (HRQOL), faecal continence and bowel function of patients with rectal cancer who underwent preoperative chemoradiotherapy (pCRT) in a cross-sectional setting. Out of 185 consecutive patients who underwent pCRT for rectal cancer from 1994 to 2004 at a single institution, 101 were eligible for the study. Causes of exclusion were: death (n = 38), not radical surgery or recurrence (n = 21), presence of stoma at the time of the survey (n = 15), lost to follow-up (n = 6) and miscellaneous (n = 4). Eligible patients were asked to complete: the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30, the disease specific colorectal module (EORTC QLQ-CR38) and faecal incontinence and bowel function questionnaires. HRQOL outcomes were compared with reference data from the general population, and the association among clinical variables and HRQOL was also investigated with linear regression analyses. Questionnaires were completed by 80% of eligible patients. Compared to population-based norms, patients showed clinically meaningful worse outcomes in terms of constipation and diarrhoea. Stool fractionation (p < 0.01) and use of enema/laxative (p < 0.01) were negatively associated with global health status/QOL. Urgency negatively affected physical (p < 0.01), role (p < 0.01) and social functioning (p < 0.01). Sensation of incomplete evacuation negatively affected social functioning (p < 0.01). Although HRQOL profile of these patients is broadly similar to that of healthy subjects, there are still important limitations in terms of key symptoms. The use of validated questionnaires is crucial to provide standardised information on relevant health status areas.

Alvimopan for postoperative ileus: Only one piece of the puzzle

Alvimopan is a promising agent to speed the recovery of bowel function in patients undergoing open abdominal surgery with bowel resection who receive systemic opioids for analgesia, and it is currently the only drug therapy for the treatment of postoperative ileus that is approved for marketing in the United States. In this issue of AJHP, Bream-Rouwenhorst and Cantrell1 review the pharmacology of and clinical data for alvimopan in the treatment of postoperative ileus. See also page 1267. Clinical trials have left several unanswered questions about alvimopan’s exact place in therapy. In addition to primary outcomes, Phase III trials of alvimopan in patients who underwent bowel resection demonstrated several encouraging results, including a lower frequency of nausea and vomiting, lower rates of nasogastric tube insertion after surgery, a lower frequency of prolonged hospital stay or readmission (within 7–10 days of discharge), and a shorter time until a discharge order is written.2,–6 Although the time to a discharge order was used in the Phase III trials, the actual length of stay (LOS) was reported in the most recently published study, by Ludwig et al.6 The mean LOS in the alvimopan 12-mg group was 1 day shorter than that in the placebo group (5.2 days versus 6.2 days, p < 0.001). The investigators also reported that most patients were discharged within four hours of the discharge order being written. Reducing the adverse effects related to postoperative ileus and hastening the return of bowel function are important. However, it seems that widespread use of alvimopan would be justified only if reductions in LOS (≥1 day) and readmission rates could be realized.

Colonic J-Pouch, Coloplasty, Side-to-End Anastomosis: Meta-Analysis and Comparison of Outcomes

Preservation of rectal function after low anterior resection or proctectomy with formation of a neorectum has improved the quality of life of many patients with rectal cancers. This would mean preserving the anal sphincters and avoiding a permanent stoma while reconstructing a neorectum to improve the bowel function of patients. Following proctectomy, the traditional anastomosis will be a straight coloanal end-to-end anastomosis to restore bowel continuity. However, this is associated with very poor bowel function. The construction of a colonic J-pouch anastomosis is introduced to reduce this problem. While colonic J-pouch anastomosis is able to obviate some of the functional problems of straight coloanal anastomosis, it comes with an additional problem of pouch evacuation. Therefore, alternatives techniques, such as transverse coloplasty pouch and side-to-end coloanal anastomosis, have been adopted. The postoperative surgical and functional outcomes are discussed and appraised.

Combined prolonged-release oxycodone and naloxone improves bowel function in patients receiving opioids for moderate-to-severe non-malignant chronic pain: a randomised controlled trial

Background: This randomised, double-blind, double-dummy, parallel-group multicentre study assessed the impact of a total daily dose of 60-80 mg oral oxycodone prolonged-release (PR)/naloxone PR (OXN PR) as fixed-ratio combination for patients with opioid-induced constipation (OIC) having moderate-to-severe, non-malignant pain. Methods: During pre-randomisation patients receiving opioids for moderate-to-severe non-malignant pain were converted to oxycodone PR (OXY PR) and titrated to an effective analgesic dose. During randomisation 265 patients on a stable OXY PR dose (60-80 mg/day) and with OIC were included in the full analysis population to receive OXN PR or OXY PR alone. Primary outcome was improvement in symptoms of constipation as measured by the Bowel Function Index (BFI). Secondary/exploratory outcomes examined analgesic efficacy and other bowel function parameters. Results: After 4 weeks of treatment, patients receiving OXN PR showed a significant improvement in bowel function compared with those in the OXY PR group (-14.9; 95% CI: -17.9, -11.9; p<0.0001) as measured by BFI which was seen after only 1 week of treatment continuing to the end of the study. After 4 weeks of treatment, patients receiving OXN PR had a median number of 3.0 complete spontaneous bowel movements (CSBM) per week compared with only 1.0 for OXY PR alone. Laxative intake was lower in the OXN PR than the OXY PR group. Furthermore, improvements in bowel function were achieved without loss of analgesic efficacy; pain intensity scores were comparable between the groups and consistent for duration of the study. Most frequently reported adverse events were consistent with those reported for opioid analgesics; no new or unexpected adverse reactions attributable to OXN PR used in higher doses were observed. Conclusion: This study shows that the fixed-ratio combination of OXN PR is superior to OXY PR alone in terms of bowel function, while providing effective equivalent analgesia.

A comparison of the effect of loperamide in oral or suppository form vs placebo in patients with ileo-anal pouches

Objective The effect of the anti-diarrhoeal drug, loperamide hydrochloride, on bowel function in patients with an ileo-anal pouch was studied by means of a blinded, three-tailed, case-controlled and randomized crossover trial, using a daily dose of 12 mg in either oral (4 mg t.d.s.) or suppository (6 mg b.d.) form. Patients and methods Daily stool frequency was recorded in a diary and an objective measure of pouch motor function was obtained at the end of each treatment phase. Ten subjects (seven males, three females) aged 23–50 years (median 38 years) were studied 9–48 months (median 27 months) after ileostomy closure. Eight pouches had been constructed for ulcerative colitis and two for familial adenomatous polyposis (9J, 1W). Results Mean daily stool frequency during the oral loperamide phase was lower than during both the placebo (P=0.05) and suppository (P < 0.02) phases. Stool frequency did not differ significantly between placebo and suppository phases. There was a strong inverse correlation between mean daily stool frequency and pouch capacity (r=–0.82 after both oral and suppository phases). Large isolated pouch contractions were evident in five of eight subjects studied; suppression was observed in two of the five after oral loperamide and in three of the five after loperamide suppositories. Rhythmic pouch contractions were seen in four subjects and suppression was evident after loperamide suppositories (but not after oral loperamide) in three. A daily oral dose of 12 mg loperamide significantly lowered stool frequency in pouch patients and modified some aspects of pouch contraction. Loperamide suppositories produced more prominent suppression of pouch contractions but did not lower stool frequency. Conclusion This suggests that the beneficial effect of oral loperamide is primarily due to its action on intestine proximal to the pouch itself.

The Food and Drug Administration Approves Methylnaltrexone Bromide for Opioid-Induced Constipation

The US Food and Drug Administration (FDA) on April 24, 2008, approved methylnaltrexone bromide (Relistor) to help restore bowel function in patients with late-stage, advanced illness who are receiving opioids on a continuous basis to help alleviate their pain. Opioids are often prescribed on a continuous basis for patients with late-stage, advanced illness to help alleviate pain. This includes patients with a diagnosis of incurable cancer, end-stage chronic obstructive pulmonary disease, congestive heart failure, Alzheimer's disease with dementia, HIV/AIDS, or other advanced illnesses. The FDA says methylnaltrexone bromide acts by blocking opioid entrance into the cells, thus allowing the bowels to continue to function normally. “This new drug will be helpful to patients who experience severe constipation associated with the continuous use of morphine or other opioids, which are an important part of care for patients with late-stage, advanced illness,” said Joyce Korvick, MD, deputy director of the Division of Gastroenterology Products at the FDA. Methylnaltrexone bromide is injectable and can be administered as needed, but not to exceed 1 dose in a 24-hour period. The recommended starting schedule is 1 dose every other day as needed for patients with late-stage, advanced illness. The drug is not recommended for patients with known or suspected intestinal obstruction. The FDA notes that common side effects include abdominal pain, gas, nausea, dizziness and diarrhea. “If severe diarrhea, vomiting, nausea or abdominal pain occurs while taking methylnaltrexone bromide, patients should discontinue use of the medication in consultation with their health care professional,” the agency cautions. The safety and effectiveness of the drug was demonstrated in clinical studies conducted by the sponsors. The 2 randomized, double-blind, placebo-controlled studies involving a total of 287 participants were conducted over a 4-month period. The median age of the study participants was 68 years, and 51% of the participants were women. In both studies, all patients had advanced, late-stage illnesses with a life expectancy of <6 months. Before treatment with methylnaltrexone bromide, participants had either <3 bowel movements in the week before treatment or no bowel movement for >2 days. Patients treated with the drug had a significantly higher rate of elimination than those receiving placebo. The safety and efficacy of methylnaltrexone bromide have not been studied in pediatric populations. The drug is manufactured by Wyeth Pharmaceuticals Inc., Philadelphia, and Progenics Pharmaceuticals, Tarrytown, New York.

Effect of early oral intake on postoperative bowel function in patients undergoing lower extremities surgery under epidural anesthesia

Background: Early oral intake (EOI) associated with early recovery of normal bowel function has been shown to be an important determinant for improving patients' satisfaction. We investigated the tolerability of EOI and its effects on the recovery of bowel function after epidural anesthesia. Methods: A prospective randomized trial of patients undergoing lower extremities surgery under epidural anesthesia was performed. A liquid drink was given to 150 patients in the EOI group 1 hours after surgery, and to 150 patients in the delayed oral intake (DOI) group 8 hours after surgery. We recorded presence of bowel sounds immediately after operation, symptoms of ileus, time to the first flatus, time to the first defecation, degree of appetite before the first meal, and patients' satisfaction. Results: There was no significant difference in the presence of immediate postoperative bowel sounds, the degree of appetite before the first meal, mild ileus, and severe ileus between groups. Time to the first flatus and time to the first defecation in the EOI group were shorter than those of the DOI group. The patients' satisfaction in the EOI group was higher than that of the DOI group. Conclusions: For uncomplicated patients undergoing lower extremities under epidural anesthesia, beginning oral hydration as early as 1 hour after the operation is safe and well tolerated and resulting in faster recovery of bowel function and higher patients' satisfaction. (Korean J Anesthesiol 2008; 55: 282~5)