Management Of Postoperative Ileus Research Articles

An outline of the management and prevention of postoperative ileus: A review.

Postoperative ileus (POI) is a prevalent surgical complication, which results in prolonged hospitalization, patient distress, and substantial economic burden. The literature aims to present a brief outline of interventions for preventing and treating POI post-surgery. Data from 2014 to 2023 were gathered from reputable sources like PubMed, PubMed Central, Google Scholar, Research Gate, and Science Direct. Inclusion criteria focused on studies exploring innovative treatments and prevention strategies for POI, using keywords such as novel POI treatments, non-pharmacological prevention, POI incidence rates, POI management, and risk factors. The findings revealed that integration of preventive measures such as coffee consumption, chewing gum, probiotics, and use of dikenchuto within enhanced recovery programs has significantly reduced both the frequency and duration of POI, without any adverse effects, with minimally invasive surgical approaches showing promise as an additional preventive strategy. While treatment options such as alvimopan, NSAIDs, and acupuncture have demonstrated efficacy, the use of lidocaine has raised concerns due to associated adverse effects. The ongoing exploration of novel therapeutic strategies such as targeting the mast cells, vagal nerve stimulation and tight junction protein, and prokinetic-mediated instigation of the cholinergic anti-inflammatory trail not only holds promise for enhanced treatment but also deepens the understanding of intricate cellular and molecular pathways underlying POI. POI presents a complex challenge in various surgical specialties, necessitating a multifaceted management approach. The integration of preventive and treatment measures within enhanced recovery programs has significantly reduced POI frequency and duration.

Real-World Data on Liposomal Bupivacaine and Inpatient Hospital Costs After Colorectal Surgery.

This study compared costs of care among colorectal surgery patients who received liposomal bupivacaine versus those who did not (control) from a health institution perspective. This pharmacoeconomic evaluation was conducted among adults undergoing open or minimally invasive colorectal resection at an academic medical center from May 2016 to February 2018. Healthcare resource utilization was derived from the electronic health record. Total cost of care (2018 USD) was analyzed using a generalized linear model adjusted for American Society of Anesthesiologists score, enhanced recovery after surgery management, open surgery, opioid use before surgery, height, cancer, and age. The primary analysis used public costs. A sensitivity analysis used internal costs from the hospital to maximize internal validity. Of 486 included patients, 286 (59%) received liposomal bupivacaine. Total cost of care using public costs included perioperative local anesthetics (mean±standard deviation [SD]: $392±74 liposomal bupivacaine versus $8±13 control), analgesics within 48h after surgery (mean±SD: $132±99 liposomal bupivacaine versus $117±127 control), postoperative ileus management (mean±SD: $5±51 liposomal bupivacaine versus $65±284 control), and hospital length of stay (mean±SD: $4459±3576 liposomal bupivacaine versus $7769±7082 control). Liposomal bupivacaine was associated with an adjusted absolute difference in total cost of care of -$1435 (95% confidence interval -$2401 to -$470; P=0.004) using public costs and -$1345 (95% confidence interval -$2215 to -$476; P=0.002) using internal costs. Use of liposomal bupivacaine in colorectal surgery was associated with a significant reduction in total cost of care that was predominately driven by reduced costs for hospital stay and postoperative ileus management despite higher medication costs.

Prevention and Management of Postoperative Ileus: A Review of Current Practice.

Postoperative ileus (POI) has long been a challenging clinical problem for both patients and healthcare physicians alike. Although a standardized definition does not exist, it generally includes symptoms of intolerance to diet, lack of passing stool, abdominal distension, or flatus. Not only does prolonged POI increase patient discomfort and morbidity, but it is possibly the single most important factor that results in prolongation of the length of hospital stay with a significant deleterious effect on healthcare costs in surgical patients. Determining the exact pathogenesis of POI is difficult to achieve; however, it can be conceptually divided into patient-related and operative factors, which can further be broadly classified as neurogenic, inflammatory, hormonal, and pharmacological mechanisms.Different strategies have been introduced aimed at improving the quality of perioperative care by reducing perioperative morbidity and length of stay, which include Enhanced Recovery After Surgery (ERAS) protocols, minimally invasive surgical approaches, and the use of specific pharmaceutical therapies. Recent studies have shown that the ERAS pathway and laparoscopic approach are generally effective in reducing patient morbidity with early return of gut function. Out of many studies on pharmacological agents over the recent years, alvimopan has shown the most promising results. However, due to its potential complications and cost, its clinical use is limited. Therefore, this article aimed to review the pathophysiology of POI and explore recent advances in treatment modalities and prevention of postoperative ileus.

EP.FRI.132 Current practice in the investigation and management of post-operative ileus

Abstract Post-operative ileus is non-obstructive impairment of gastrointestinal motility after surgery. Treatment involves nil-by-mouth, correction of electrolytes and stopping aggravating medications. There is no national/trust guideline for investigation and management of post-operative ileus. Aim To assess current practice in investigation and management of post-operative ileus. Method All patients with a diagnosis of post-operative ileus on surgical wards at a London hospital between November - December 2020 were identified using clinical coding. Their clinical notes were reviewed and common themes explored. Results 16 patients were diagnosed with post-operative ileus. 12 (75%) patients were male, with a median age of 60 (IQR: 28). 10 (63%) were open procedures, majority being colorectal (10; 63%), cardiothoracic (3; 19%), urological (2; 13%), vascular (1; 6%) operations. Average time between operation and diagnosis was 5.2 (range: 2-14) days. Only 2 (12.5%) patients had documented auscultation of bowel sounds at initial assessment. 8 (50%) patients had imaging to confirm diagnosis (AXR; 5, CT scan; 4). Majority (15; 94%) of patients had serum magnesium and potassium checked at diagnosis. Patients with serum potassium <4.0mmol/L (5) and magnesium <0.7mmol/L (2) had intravenous supplementation. 14 (88%) were administered Hartmann’s solution. 10 (63%) patients were made nil-by-mouth and 15 (94%) had a Ryles tube inserted. 2 (12.5%) patients were prescribed a prokinetic, and only 2 had either opioids or laxatives stopped. No patients were offered gum. Conclusion There is apparent clinical variation in investigation and management of post-operative ileus. We plan to develop an evidence-based trust guideline to reduce unwarranted clinical variation.

928 Current Practice in The Investigation and Management of Post-Operative Ileus

Abstract Introduction Post-operative ileus is non-obstructive impairment of gastrointestinal motility after surgery. Treatment involves nil-by-mouth, correction of electrolytes and stopping aggravating medications. There is no current national/trust guideline for investigation and management of post-operative ileus. Aim To assess current practice in investigation and management of post-operative ileus on surgical wards at St Thomas’s Hospital. Method All patients with a diagnosis of post-operative ileus on surgical wards between November - December 2020 were identified. Their clinical notes were reviewed, and common themes explored. Results 16 patients were diagnosed with post-operative ileus. 12 (75%) patients were male, with a median age of 60 (IQR: 28). 10 (63%) were open procedures, majority being colorectal (10; 63%), cardiothoracic (3; 19%), urological (2; 13%), vascular (1; 6%) operations. Average time between operation and diagnosis was 5.2 (range: 2-14) days. Bowel sounds were auscultated in only 2 (12.5%) patients at initial assessment. 8 (50%) patients had imaging to confirm diagnosis (AXR; 5, CT scan; 4). Majority (15; 94%) of patients had serum magnesium and potassium checked at diagnosis. All patients with serum potassium <4.0mmol/L (5) and magnesium <0.7mmol/L (2) had intravenous supplementation. 14 (88%) were administered Hartmann’s solution. 10 (63%) patients were made nil-by-mouth and 15 (94%) had a Ryles tube inserted. 2 (12.5%) patients were prescribed a prokinetic, and only 2 had either opioids or laxatives stopped. No patients were offered gum. Conclusions There is apparent clinical variation in investigation and management of post-operative ileus. We plan to develop an evidence-based trust guideline to reduce unwarranted clinical variation.

PSU5 Liposomal Bupivacaine and Inpatient Hospital Costs after Colorectal Surgery

To compare total costs of care between patients who received liposomal bupivacaine (LB) versus those who did not (control) from a health institution perspective. This economic evaluation was conducted among adults undergoing open or minimally invasive colorectal resection at an academic medical center from May 2016 to February 2018. Patients with surgery after hospital day 2 or ostomy were excluded. The primary analysis used public charges. A sensitivity analysis used hospital-specific costs. Healthcare resource utilization was derived from the electronic health record. Total costs of care (in 2018 USD) were analyzed using a generalized linear model adjusted for American Society of Anesthesiologists score, enhanced recovery after surgery management, open surgery, opioid use before surgery, height, cancer, and age. Of 486 included patients, 286 (59%) received LB. Total costs of care using public charges included perioperative local anesthetic use (mean ± SD; $392 ± 74 LB vs. $8 ± 13 control), analgesia 48-hour after surgery ($132 ± 99 LB vs. $117 ± 127 control), postoperative ileus management ($5 ± 51 LB vs. $65 ± 284 control), and hospital length of stay ($4,459 ± 3,576 LB vs. $7,769 ± 7,082 control). After adjusting for covariates, LB was associated with an average reduction in total costs of care of $1,435 (95%CI [470 to 2,401]; p=0.004) using public charges and $1,345 (95%CI [476 to 2,215]; p=0.002) using hospital-specific costs. In a sensitivity analysis where administration of LB was assumed to increase operating room time by 5 minutes, LB was associated with a significant reduction in total costs of care as long as cost per minute of operating room time was ≤$80. Following colorectal surgery, LB was associated with a significant reduction in total costs of care that were predominately driven by reduced costs for hospital stay and postoperative ileus management despite higher medication costs.

The Efficacy of Chewing Gum in Postoperative Ileus Management After Robot Assisted Laparoscopic Radical Prostatectomy: A Prospective Randomized Study

Aim:To examine the efficacy of chewing gum on bowel motility in the early postoperative period in patients with prostate cancer undergoing robot-assisted laparoscopic prostatectomy (RALP) we prepared this study. Materials and Methods:The study was obtained from the local ethics committee. A total of 67 patients who underwent general anaesthesia were included in the study. Patients were divided into two groups as chewing gum group (Group G) and the control group (Group C). In the postoperative period, the patients in the Group G were chewed gum in the postoperative period. Bowel function improvement was inspected. The study was terminated at the first gas passage occurred. This time interval was noted. Demographic datas, intraoperative parameters, surgical results were analysed and compared. The first time of bowel movement, length of hospitalisation, and surgical wound site pain and abdominal pain intensity according to the Visual Analogue Scale (VAS) were recorded at the 12th 24th and 36th postoperative hours. Results:At the end of the study, 23 patients in the Group C and 25 patients in Group G were evaluated. There was no significant difference in demographic datas between the groups. No statistically significant difference was observed in all intraoperative parameters. First bowel movements and postoperative abdominal and surgical wound site pain at the 24th and 36th hours were significantly lower in Group G compared to Group C. Conclusions:This study indicated that chewing gum is also efficient in early solution of postoperative ileus.

The Impact of Sham Feeding with Chewing Gum on Postoperative Ileus Following Colorectal Surgery: a Meta-Analysis of Randomised Controlled Trials

BackgroundChewing gum as a form of sham feeding is an inexpensive and well-tolerated means of promoting gastrointestinal motility following major abdominal surgery. Although recognised by the Enhanced Recovery After Surgery (ERAS) Society as one of the multimodal approaches to expedite recovery after surgery, strong evidence to support its use in routine postoperative practice is lacking. MethodologyA comprehensive literature review of all randomised controlled trials (RCTs) was performed in the Medline and Embase databases between 2000 and 2019. Studies were selected to compare the use of chewing gum versus standard care in the management of postoperative ileus (POI) in adults undergoing colorectal surgery. The primary outcome assessed was the incidence of POI. Secondary outcomes included time to passage of flatus, time to defecation, total length of hospital stay and mortality. ResultsSixteen RCTs were included in the systematic review, of which ten (970 patients) were included in the meta-analysis. The incidence of POI was significantly reduced in patients utilising chewing gum compared to those having standard care (RR 0.55, 95% CI 0.39, 0.79, p = 0.0009). These patients also had a significant reduction in time to passage of flatus (WMD − 0.31, 95% CI − 0.36, − 0.26, p < 0.00001) and time to defecation (WMD − 0.47, 95% CI − 0.60, − 0.34, p < 0.00001), without significant differences in the total length of hospital stay or mortality. ConclusionThe use of chewing gum after colorectal surgery is a safe and effective intervention in reducing the incidence of POI and merits routine use alongside other ERAS pathways in the postoperative setting.

Management of postoperative ileus after robot-assisted radical prostatectomy

Introduction: The use of robot-assisted radical prostatectomy (RARP) for localized prostate cancer has increased in recent years. Postoperative ileus (POI) is the most common perioperative complication leading to delayed discharge after RARP. The incidence and management of prolonged POI from at our institution were reviewed. Materials and Methods: A total of 958 RARPs were reviewed. Prolonged POI was defined as intolerance of an oral diet that continued until the postoperative day 6 and beyond. All data including the patients' characteristics, comorbidities, perioperative outcome, and management of prolonged POI were assessed. Results: Seven patients experienced prolonged POI. Four of these seven patients (57%) recovered under conservative treatment. Three patients (43%) needed surgical reexploration were identified by abdominal computed tomography (CT) scan, including one adhesive intestinal obstruction and two incarcerated inguinal hernias. The laparoscopic reexplorations were successfully performed for the three patients. Conclusion: For patients with prolonged POI failing initial conservative treatment, a prompt CT survey is crucial for early detection of patients requiring surgical intervention, helps to avoid intra-abdominal adhesion during the exploratory laparotomy and reduces associated surgical complications.

Therapeutic management of postoperative ileus

Postoperative ileus is one of the most common complications in patients after abdominal surgery and is a major determinant of recovery after surgery. It leads to increased postoperative morbidity, prolonged hospital stay, and increased costs. The pathogenesis of postoperative ileus is multifactorial, including pharmacological, neurogenic, and inflammatory mechanisms. In this review, we discuss the current therapeutic strategies for postoperative ileus.

The Use of Coffee, Chewing-Gum and Gastrograffin in the Management of Postoperative Ileus: A Review of Current Evidence

Postoperative ileus is one of the main complications in the postoperative period. New measures appeared with the introduction of “fast-track surgery” to accelerate recovery: coffee, chewing gum and gastrograffin. We performed a summary of current evidence, reviewing articles from MEDLINE, Cochrane Database of Systematic Reviews, ISI Web of Science, and SCOPUS databases. Employed search terms were “postoperative ileus” AND (“definition” OR “epidemiology” OR “risk factors” OR “Management”). We selected 44 articles: 9 systematic reviews 11 narrative reviews, 13 randomized clinical trials, 6 observational studies, and the remaining 5 scientific letters, assumptions, etc. There is little literature about this topic, studies are heterogeneous, with disparity in the results. In addition, they only focus on colorectal and gynecological surgery. New high-quality studies are needed, preferably randomized clinical trials, in order to clarify the usefulness of these measures.

Extrapyramidal side effects following subcutaneous metoclopramide injection for the treatment of post operative ileus

SummaryMetoclopramide is used for the management of post operative ileus in horses for its gastrointestinal prokinetic effects. Adverse extrapyramidal signs have been reported following its use in horses as well as in man. This report describes the clinical signs exhibited during an adverse reaction suspected to be associated with subcutaneous administration of 0.25 mg/kg bwt metoclopramide at 6 h intervals.

Alvimopan combined with enhanced recovery strategy for managing postoperative ileus after open abdominal surgery: a systematic review and meta-analysis

BackgroundTo assess the efficacy and safety of alvimopan in conjunction with enhanced recovery strategy, compared with this strategy alone, in management of postoperative ileus in patients undergoing open abdominal surgery. MethodsElectronic databases were comprehensively searched for relevant randomized controlled trials. We were interested in doses of 6 and 12 mg. The efficacy end points included the time to recovery of full gastrointestinal (GI) function (a composite end point measured by the time to first toleration of solid food [SF] and the time to first passage of stool, GI-2), the recovery of upper (SF) or the lower (the time to first bowel movement, BM) GI function, and the length of hospital stay (the time to discharge order written). Safety end points included GI-related, non-GI–related, and serious adverse events. These parameters were all analyzed by RevMan 5.3 software. ResultsNine randomized controlled trials involving 4075 patients were enrolled in this study. The pooled results showed that alvimopan significantly decreased the time to GI-2 recovery (6 mg, hazard ratio [HR] = 1.45, P < 0.00001; 12 mg, HR = 1.59, P < 0.00001), BM (6 mg, HR = 1.54, P < 0.00001; 12 mg, HR = 1.74, P = 0.0002), and the time to discharge order written (6 mg, HR = 1.37, P < 0.00001; 12 mg, HR = 1.34, P < 0.00001) compared with the placebo group. However, SF was significantly reduced in 6 mg group (HR = 1.23, P = 0.008) rather than 12 mg group (HR = 1.14, 95% confidence interval 1.00, 1.30, P = 0.04). The incidence of some GI-related and serious adverse events were significantly lower in the alvimopan group than the placebo group, and the dose of 12 mg was superior to 6 mg in this regard. ConclusionsAlvimopan can accelerate recovery of GI function (especially for the lower GI tract), shorten the length of hospital stay, and reduce postoperative ileus-related morbidity without compromising opioid analgesia in an enhanced recovery setting.

Effects of Bit Chewing on Right Upper Quadrant Intestinal Sound Frequency in Adult Horses

Many therapies have been proposed to prevent and treat postoperative ileus (POI) in horses, but to date none is considered fully effective. Various methods have been considered in the prevention of POI in humans too, and among these, gum chewing is gaining a role, reducing time from surgery to first fecal passage and hospitalization time. The aim of the present study is to produce a method to consistently induce horses at chewing without ingesting food and to evaluate its effects on gut sounds in healthy horses. Animals used in this study were 10 adult horses of both genders. A digital phonendoscope was positioned on the right upper flank. A first registration was started and lasted for five consecutive minutes. Then a snaffle bit with toggles was applied to the horse, and a second registration was obtained in the following 15 minutes. Recording sessions were cut into 5-minute subsessions and blindly assessed by two operators that calculated the number of borborygmi per minute in each session. Application of a bit produced consistent mastication and swallowing in all horses for a period of 20 minutes or more. There was a significantly different increase in short (<3 seconds) gut sounds in the first 5 minutes after application of the bit. In conclusion, mastication of a bit consistently caused an increase in gut sounds on the right upper quadrant. Bit chewing can be easily obtained in horses at rest, and further evaluation as an adjunctive element in the management of POI is warranted.

1590 THE NOVEL OPIOID RECEPTOR ANTAGONIST ALVIMOPAN MINIMIZES POST-OPERATIVE ILEUS FOLLOWING RADICAL CYSTECTOMY

You have accessJournal of UrologyBladder Cancer: Invasive II1 Apr 20121590 THE NOVEL OPIOID RECEPTOR ANTAGONIST ALVIMOPAN MINIMIZES POST-OPERATIVE ILEUS FOLLOWING RADICAL CYSTECTOMY Joel Bigley, Jeffrey Tomaszewski, Jeffrey Gingrich, Benjamin Davies, and Ronald Hrebinko Joel BigleyJoel Bigley Pittsburgh, PA More articles by this author , Jeffrey TomaszewskiJeffrey Tomaszewski Pittsburgh, PA More articles by this author , Jeffrey GingrichJeffrey Gingrich Pittsburgh, PA More articles by this author , Benjamin DaviesBenjamin Davies Pittsburgh, PA More articles by this author , and Ronald HrebinkoRonald Hrebinko Pittsburgh, PA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1363AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Post-operative ileus contributes significantly to the morbidity associated with radical cystectomy and urinary diversion (RCx). Alvimopan (Entereg) is a novel peripherally acting μ-opioid receptor antagonist approved by the FDA to accelerate upper and lower gastrointestinal recovery in the management of postoperative ileus following bowel resection. Our objective was to evaluate the effect of alvimopan on time to return of bowel function and hospital length of stay in a retrospective matched-cohort analysis of patients undergoing radical cystectomy. METHODS 24 consecutive patients who had undergone RCx and received perioperative alvimopan were matched chronologically for surgeon and type of urinary diversion (1:2) to patients not receiving alvimopan (n=48). Patients in the treatment group received alvimopan 12mg twice daily until hospital discharge. Patients were excluded if they had undergone radical cystectomy as part of a larger surgical oncology operation or did not survive to hospital discharge. Primary outcomes of interest included time to GI-2 (toleration of solid food and first bowel movement) and GI-3 (toleration of solid food and first flatus or bowel movement) recovery, hospital discharge order written, actual hospital discharge, opioid consumption, and overall postoperative ileus-related morbidity. Categorical and linear variables were compared using Fisher's exact and Mann Whitney U tests, respectively. RESULTS There was no significant differences in mean patient age, gender distribution, type of urinary diversion, or PCA usage between groups. There were no significant side effects reported in patients receiving alvimopan. Alvimopan significantly decreased time to return of bowel function (GI-2: 104±33hr vs. 142 ± 53hr, p<0.01; GI-3: 102±34hr vs. 140±53hr, p<0.01). Hospital length of stay was significantly shorter in patients treated with alvimopan (5.8±1.3d vs. 7.5±2.9d, p<0.05). The 30-day readmission rate for vomiting, adynamic ileus, or partial small bowel obstruction in patients receiving alvimopan was 0% compared to 10.4% in the control group. CONCLUSIONS Consistent with clinical trial data in general surgery series, alvimopan use following radical cystectomy shortened hospital length of stay and decreased time to return of bowel function by approximately 1.5 days. These results support the clinical benefit of alvimopan in patients undergoing radical cystectomy. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e643-e644 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joel Bigley Pittsburgh, PA More articles by this author Jeffrey Tomaszewski Pittsburgh, PA More articles by this author Jeffrey Gingrich Pittsburgh, PA More articles by this author Benjamin Davies Pittsburgh, PA More articles by this author Ronald Hrebinko Pittsburgh, PA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Management of Postoperative Ileus

Postoperative ileus, a temporary cessation in bowel motility, is a common and significant complication of major surgery. Consequences of postoperative ileus include increased patient discomfort, delayed time to adequate nutrition, prolonged length of stay, and increased cost to the patient and healthcare system. The traditional, multi-modal approach to the resolution of postoperative ileus includes opioid minimization, early ambulation, and early feeding. Newer medications, such as methlynaltrexone and alvimopan (which are peripherally acting mu opioid receptor antagonists), have become available and have proven beneficial for use with postoperative ileus.

Economic Analysis of Alvimopan for Prevention and Management of Postoperative Ileus

To determine whether alvimopan for prevention of postoperative ileus in patients undergoing small- or large-bowel resection by laparotomy is associated with lower total costs compared with standard care. Pharmacoeconomic analysis using a formal decision model. Four phase III clinical trials, two pooled analyses, and one meta-analysis. A cohort of patients who underwent bowel resection with primary anastomosis by laparotomy and received either standardized, accelerated postoperative care (usual care) or usual care plus alvimopan. Clinical outcomes, obtained from pooled analyses of published studies, were time to discharge order written, postoperative nasogastric tube insertion, postoperative ileus-related readmission within 7days, and occurrence of nausea and vomiting. Cost inputs included drugs, nursing labor, readmissions, and hospitalizations. Costs were assessed by determining the net cost of alvimopan use and subsequent reduction in length of stay. Sensitivity and scenario analyses were conducted. Costs for alvimopan were $570 based on an average of 9.5 doses. Given the 18.4-hour mean reduction in time to discharge order written, use of alvimopan reduced hospitalization costs by $2021. Mean difference in overall cost of care, as determined by Monte Carlo simulation, was $1168 (95% certainty interval -$437 to $5879), favoring the use of alvimopan. In the sensitivity analysis, association of alvimopan with lower costs was robust to several changes in key parameters including cost and number of doses of alvimopan, time to discharge order written, readmission rates, and hospitalization cost. In the scenario analyses, alvimopan use yielded a net cost of $226 when no difference in time to discharge order written was assumed. In the scenario analysis using data from a study that did not enforce opioid use, alvimopan resulted in a cost saving of $65/patient. Alvimopan was cost saving for prevention of postoperative ileus in patients undergoing bowel resection by laparotomy, although these potential cost savings were highly dependent on a difference in time to discharge order written. This finding is not applicable to the less-invasive laparoscopic surgical approach for which quality data on alvimopan use are lacking. Limitations of this analysis included use of time to discharge order written as a proxy for length of stay and difficulty interpreting study results due to inconsistent reporting and conduct of the clinical trials evaluating alvimopan. More research is needed to determine the cost-effectiveness of alvimopan.

Enhanced recovery after surgery (ERAS) protocols: Time to change practice?

Radical cystectomy with pelvic lymph node dissection remains the standard treatment for patients with muscle invasive bladder cancer. Despite improvements in surgical technique, anesthesia and perioperative care, radical cystectomy is still associated with greater morbidity and prolonged in-patient stay after surgery than other urological procedures. Enhanced recovery after surgery (ERAS) protocols are multimodal perioperative care pathways designed to achieve early recovery after surgical procedures by maintaining preoperative organ function and reducing the profound stress response following surgery. The key elements of ERAS protocols include preoperative counselling, optimization of nutrition, standardized analgesic and anesthetic regimens and early mobilization. Despite the significant body of evidence indicating that ERAS protocols lead to improved outcomes, they challenge traditional surgical doctrine, and as a result their implementation has been slow.The present article discusses particular aspects of ERAS protocols which represent fundamental shifts in surgical practice, including perioperative nutrition, management of postoperative ileus and the use of mechanical bowel preparation.

Factors associated with survival of epiploic foramen entrapment colic: A multicentre, international study

Epiploic foramen entrapment (EFE) has been associated with reduced post operative survival compared to other types of colic but specific factors associated with reduced long-term survival of these cases have not been evaluated in a large number of horses using survival analysis. To describe post operative survival of EFE cases and to identify factors associated with long-term survival. A prospective, multicentre, international study was conducted using clinical data and long-term follow-up information for 126 horses diagnosed with EFE during exploratory laparotomy at 15 clinics in the UK, Ireland and USA. Descriptive data were generated and survival analysis performed to identify factors associated with reduced post operative survival. For the EFE cohort that recovered following anaesthesia, survival to hospital discharge was 78.5%. Survival to 1 and 2 years post operatively was 50.6 and 34.3%, respectively. The median survival time of EFE cases undergoing surgery was 397 days. Increased packed cell volume (PCV) and increased length of small intestine (SI) resected were significantly associated with increased likelihood of mortality when multivariable analysis of pre- and intraoperative variables were analysed. When all pre-, intra- and post operative variables were analysed separately, only horses that developed post operative ileus (POI) were shown to be at increased likelihood of mortality. Increased PCV, increased length of SI resected and POI are all associated with increased likelihood of mortality of EFE cases. This emphasises the importance of early diagnosis and treatment and the need for improved strategies in the management of POI in order to reduce post operative mortality in these cases. The present study provides evidence-based information to clinicians and owners of horses undergoing surgery for EFE about long-term survival. These results are applicable to university and large private clinics over a wide geographical area.

Abdominal surgery inhibits circulating acyl ghrelin and ghrelin-O-acyltransferase levels in rats: role of the somatostatin receptor subtype 2.

Clinical studies are evaluating the efficacy of synthetic ghrelin agonists in postoperative ileus management. However, the control of ghrelin secretion under conditions of postoperative gastric ileus is largely unknown. Peripheral somatostatin inhibits ghrelin secretion in animals and humans. We investigated the time course of ghrelin changes postsurgery in fasted rats and whether somatostatin receptor subtype 2 (sst(2)) signaling is involved. Abdominal surgery (laparotomy and 1-min cecal palpation) induced a rapid and long-lasting decrease in plasma acyl ghrelin levels as shown by the 64, 67, and 59% reduction at 0.5, 2, and 5 h postsurgery, respectively, compared with sham (anesthesia alone for 10 min, P < 0.05). Levels were partly recovered at 7 h and fully restored at 24 h. The percentage of acyl ghrelin reduction was significantly higher than that of desacyl ghrelin at 2 h postsurgery and not at any other time point. This was associated with a 48 and 23% decrease in gastric and plasma ghrelin-O-acyltransferase protein concentrations, respectively (P < 0.001). Ghrelin-positive cells in the oxyntic mucosa expressed sst(2a) receptor and the sst(2) agonist S-346-011 inhibited fasting acyl ghrelin levels by 64 and 77% at 0.5 and 2 h, respectively. The sst(2) antagonist S-406-028 prevented the abdominal surgery-induced decreased circulating acyl ghrelin but not the delayed gastric emptying assessed 0.5 h postinjection. These data show that activation of sst(2) receptor located on gastric X/A-like cells plays a key role in the rapid inhibition of circulating acyl ghrelin induced by abdominal surgery while not being primarily involved in the early phase of postoperative gastric ileus.