Management Of Postoperative Ileus Research Articles

Risk factors for postoperative ileus after urologic laparoscopic surgery

PurposeAlthough its incidence has decreased with the widespread use of less invasive surgical techniques including laparoscopic surgery, postoperative ileus remains a common postoperative complication. In the field of urologic surgery, with the major exception of radical cystectomy, few studies have focused on postoperative ileus as a complication of laparoscopic surgery. The present study aims to offer further clues in the management of postoperative ileus following urological laparoscopic surgery through an assessment of the associated risk factors.MethodsThe medical records of 267 patients who underwent laparoscopic surgery between February 2004 and November 2009 were reviewed. After excluding cases involving radical cystectomy, combined surgery, open conversion, and severe complications, a total of 249 patients were included for this study. The subjects were divided into a non-ileus group and an ileus group. The gender and age distribution, duration of anesthesia, American Society of Anesthesiologists Physical Status Classification Score, body mass index, degree of operative difficulty, presence of complications, surgical procedure and total opiate dosage were compared between the two groups.ResultsOf the 249 patients, 10.8% (n = 27) experienced postoperative ileus. Patients with ileus had a longer duration of anesthesia (P = 0.019), and perioperative complications and blood loss were all correlated with ileus (P = 0.000, 0.004, respectively). Multiple linear regression analysis showed that the modified Clavien classification was an independent risk factor for postoperative ileus (odds ratio, 5.372; 95% confidence interval, 2.084 to 13.845; P = 0.001).ConclusionPostoperative ileus after laparoscopic urologic surgery was more frequent in patients who experienced more perioperative complications.

On “Pathogenesis and Management of Postoperative Ileus” (Clin Colon Rectal Surg 2009;22:47–50)

I read with great interest the article in your Volume 22 issue by Carroll and Alavi regarding the pathogenesis and management of postoperative ileus (POI).1 Alvimopan was reviewed by the authors and concluded to show “promise in reducing POI, but needs more rigorous investigation.” Alvimopan has been extensively evaluated for the management of gastrointestinal (GI) recovery (POI) in five large, randomized, double-blind, placebo-controlled phase 3 clinical trials (>3,000 patients). The results from these clinical trials have all been published in peer-reviewed journals.2,3,4,5,6 Furthermore, alvimopan was ultimately approved by the U.S. Food and Drug Administration in 2008 to accelerate the time to upper and lower GI recovery following partial large or small bowel resection surgery with primary anastomosis.7 Although the information presented in the article is accurate, it is also incomplete. This additional information, which was not referenced in the original article, may help provide perspective to the reader about the current state of development of alvimopan. Thank you for the opportunity to comment on this interesting paper by Carroll and Alavi.

Pathogenesis and Management of Postoperative Ileus

Postoperative ileus (POI) is a predictable delay in gastrointestinal (GI) motility that occurs after abdominal surgery. Probable mechanisms include disruption of the sympathetic/parasympathetic pathways to the GI tract, inflammatory changes mediated over multiple pathways, and the use of opioids for the management of postoperative pain. Pharmacologic treatment of postoperative ileus continues to be problematic as most agents are unreliable and unsubstantiated with robust clinical trials. The selective opioid antagonist alvimopan has shown promise in reducing POI, but needs more rigorous investigation. Clinician interventions proven to be of benefit include laparoscopy, thoracic epidural anesthesia, avoidance of opioids, and early feeding. Early ambulation may also contribute to early resolution of POI; however, routine nasogastric decompression plays no role and may increase complications. Multimodal care plans remain the mainstay of treatment for POI.

Management of postoperative ileus: focus on alvimopan

Postoperative ileus (POI) is a transient loss of coordinated peristalsis precipitated by surgery and exacerbated by opioid pain medication. Ileus causes a variety of symptoms including bloating, pain, nausea, and vomiting, but particularly delays tolerance of oral diet and liquids. Thus POI is a primary determinant of hospital stay after surgery. 'Fast-track' recovery protocols, opioid sparing analgesia, and laparoscopic surgery reduce but do not eliminate postoperative ileus. Alvimopan is a mu opioid receptor antagonist that blocks the effects of opioids on the intestine, while not interfering with their centrally mediated analgesic effect. Several large randomized clinical trials have demonstrated that alvimopan accelerates the return of gastrointestinal function after surgery and subsequent hospital discharge by approximately 20 hours after elective open segmental colectomy. However, it has not been tested in patients undergoing laparoscopic surgery and is less effective in patients receiving nonsteroidal anti-inflammatory agents in a narcotic sparing postoperative pain control regimen. Safety concerns seen with chronic low dose administration of alvimopan for opioid bowel dysfunction have not been noted with its acute use for POI.

Alvimopan

Alvimopan, a trans-3,4-dimethyl-4-(3-hydroxy-phenyl) piperidine, is a selective, peripherally acting micro-opioid receptor antagonist that is available for short-term use in hospitalized patients who have undergone bowel resection. The efficacy of alvimopan in the management of postoperative ileus has been evaluated in five phase III trials; four conducted in North America and one conducted in Europe/Australasia. Patients who had undergone partial large or small bowel resection surgery with primary anastomosis were randomized to receive alvimopan 12 mg or placebo as a single oral pre-operative dose followed by twice-daily administration for up to 7 days postoperatively. In the five phase III trials, alvimopan was significantly more effective than placebo in reducing the time to recovery of upper and lower gastrointestinal (GI) function, as assessed using a two-component endpoint (GI2) comprising time to tolerance of solid food and first bowel movement. The mean time to reach the GI2 endpoint was 11-26 hours sooner with alvimopan than with placebo. In the phase III trials conducted in North America, the time to writing the hospital discharge order was 13-21 hours sooner with alvimopan than with placebo. Alvimopan did not reduce opioid-induced analgesia and/or increase the amount of opioids administered postoperatively. Short-term alvimopan was generally well tolerated in adults undergoing bowel resection.

Management of Postoperative Ileus

Postoperative ileus is an abnormal pattern of gastrointestinal motility that is common after both abdominal and nonabdominal surgeries. There are many causes of ileus, including postoperative pain and the use of narcotics for analgesia, electrolyte imbalances, and manipulation of the bowel during surgery. Despite its prevalence, there is still no reliable treatment to prevent ileus or shorten its course. This article discusses the causes of postoperative ileus and the treatment options currently available. The literature on early refeeding, gum chewing, and the use of tube feeds is reviewed. In addition, new and experimental drugs currently in development are discussed.

Review of the Pathophysiology and Management of Postoperative Ileus

Investigations in the pathophysiology and treatment of postoperative ileus continue to evolve. Bowel rest is no longer a mandatory component of postoperative recovery. Tolerance of enteral nutrition and normalization of the abdominal examination are more accurate indications of the resolution of postoperative ileus than passage of flatus or first bowel movement. A multimodal "fast track" recovery approach incorporated into a clinical pathway provides a more rapid return of intestinal function and shortened hospital stay in patients undergoing major, uncomplicated gastrointestinal surgery.

Introduction

DEAR NURSING COLLEAGUE: Postoperative ileus (POI) has emerged as a significant determining factor in the quality of the overall perioperative experience, from proper and adequate pain management to the optimization of recovery and discharge protocols. Although the transient cessation of normal gastrointestinal (GI) function after major surgery (ie, POI) has long been recognized, only recently have deeper insights into its pathophysiology and the true nature of its negative clinical impact been more fully appreciated. Perianesthesia nursing personnel, and many of their nursing colleagues, have an equivalent long history of dealing with the clinical consequences of major surgery, being forced to rely on unproven or anecdotal methods to help decrease the discomfort and other adverse effects associated with POI. This “standard of practice” has persisted for decades, but the development of new surgical and anesthesia strategies, as well as a new class of drugs, peripherally acting mu-opioid-receptor antagonists, have contributed to a renewed interest in learning how to overcome the challenges associated with POI. Some degree of POI will likely remain an inevitable response to surgery, but the long-held notion that we are essentially powerless to diminish its severity and duration is rapidly giving way to new paradigms of prevention and improved management. Combined with ongoing evaluations of alternative surgical, anesthesia, and supportive approaches, peripherally acting mu-opioid-receptor antagonists (methylnaltrexone, and in particular, alvimopan) have helped spark the design of innovative protocols to improve the perioperative experience and clinical outcomes. Nursing personnel, always on the forefront of patient management, will play key roles in the planning and implementation of these new multimodal strategies, and will help redefine the surgical team’s management of POI through heightened communication and ongoing education among themselves and their colleagues. Developed from a symposium, Redefining the Surgical Team’s Management of Postoperative Ileus, ⁎This commercially supported symposium was independent of ASPAN’s educational conference activities, although it was accredited for continuing education credit by the American Society of PeriAnesthesia Nurses. which took place during the 24th National Conference of the American Society of PeriAnesthesia Nurses in Chicago, the articles that follow will discuss the variety of approaches that have been used to manage POI and attempt to put into context the rationale for these, their potential benefit, if any, and furthermore, delineate management concerns regarding POI from the perspective of individual surgical team members: a surgeon, an anesthesiologist, and two key nursing personnel, involved in preoperative/preanesthesia and postanesthetic roles, on specific POI management points and issues. I hope you find the information and the recommendations within this supplement valuable and helpful to your nursing practice. Sincerely, Susan Carter, BSN, RN, CPAN, CAPA Guest Editor This commercially supported symposium was independent of ASPAN’s educational conference activities, although it was accredited for continuing education credit by the American Society of PeriAnesthesia Nurses. Susan Carter, BSN, RN, CPAN, CAPA, is a Staff Nurse CNIII, University of California San Diego Medical Center–Thornton Hospital, La Jolla, CA.

The Surgical Team and Outcomes Management: Focus on Postoperative Ileus

Postoperative ileus (POI) is defined as the impairment of bowel motility that occurs almost universally after major open abdominal procedures, as well as other abdominal and nonabdominal procedures. For the majority of affected patients, POI generally lasts approximately three to five days, but longer duration is not uncommon. The causes of POI are multifactorial, but can be broadly categorized into two groups: those related to the surgical procedure and those related to pharmacologic interventions (opioids). The fact that POI is generally transient and therefore self-limited should not deter the surgical team from seeking improved ways to mitigate its associated adverse effects, which can be substantial and immensely uncomfortable for the patient, and can have far-reaching implications regarding overall hospitalization costs for many types of surgeries. Optimization of POI management and prevention efforts is a responsibility of all members of the surgical team and can drastically affect the overall clinical outcome of major abdominal surgery. Depending on the individual team member's role, different perspectives and strategies may be used to achieve improved outcomes, including but not limited to hospitalization costs related to care and length of stay, resource utilization, and, perhaps most critically, patient quality of life not only immediately after surgery but also after discharge. The ability to reliably and significantly decrease the duration of POI should be readily recognized as an important objective in the management of this condition. Opioids will continue to be a mainstay of postoperative care regimens, but new agents such as peripherally acting mu-opioid-receptor antagonists may offer a unique clinical advantage by helping to reduce the adverse gastrointestinal effects of opioids while preserving their desired benefits for postoperative analgesia.

The Management of Postoperative Ileus

The Management of Postoperative Ileus

Alvimopan for the Management of Postoperative Ileus

To review the pharmacology, pharmacokinetics, clinical efficacy, safety, dosage, and administration of alvimopan, a peripherally acting mu-opioid receptor antagonist, in the management of postoperative ileus (POI). A literature search (1980-October 2004) applying the terms alvimopan, ADL 8-2698, and LY246736 was conducted using MEDLINE. Information was also obtained from scientific congress abstracts and data on file with the manufacturer. Studies and abstracts investigating alvimopan and POI were considered for inclusion; however, they were restricted to English-language articles. Alvimopan is a novel, peripherally acting mu-opioid receptor antagonist that is currently under evaluation for the management of POI. POI presents significant clinical challenges that can delay patient recovery and contribute to increased morbidity and prolonged hospitalization after surgery. Clinical trials have demonstrated that alvimopan, at oral doses of 6 and 12 mg, can accelerate time to recovery of gastrointestinal (GI) function and time to hospital discharge following abdominal surgery. The incidence of adverse events with alvimopan therapy was shown to be similar to that of placebo. Alvimopan is well tolerated and effective at accelerating GI recovery and time to discharge in patients who have undergone bowel resection or hysterectomy when administered prior to surgery and twice daily thereafter until discharge or for up to 7 days. Alvimopan potentially offers significant benefits for patients with POI over currently available treatments.

Evaluation of the clinical efficacy of prokinetic drugs in the management of post-operative ileus: Can retrospective data help us?

The objectives of the study were to determine whether retrospective data can be used to answer questions about the efficacy of prokinetic agents when used to treat horses with post-operative ileus (POI). We describe prevalence and mortality of POI with reference to treatment with four prokinetic agents. By combining data from two Hospitals a study population of 55 horses with POI following pedunculated lipoma obstruction (PLO) was established. Univariable and multivariable associations were determined between short term survival and potential explanatory variables. With death as outcome in multivariable models, breed and hospital were significantly associated with outcome but the use of prokinetic agents was not ( P = 0.15). However, sample size estimates indicate the low power of this study to detect differences in outcome. It was not possible definitively to evaluate the efficacy of prokinetics as treatment for POI following PLO using retrospective data. The data were suggestive of limited efficacy of prokinetics as treatment for POI. It is postulated that the identified association between hospital and survival reflects differences in clinician decision making. The study highlights the need for further prospective studies using randomised clinical trials to evaluate accurately the efficacy of prokinetic agents. This report illustrates difficulties with performing retrospective analysis of clinical data to determine the efficacy of treatment regimes.

A survey of perceptions and attitudes among European surgeons towards the clinical impact and management of postoperative ileus

Postoperative ileus (POI) can negatively affect patient recovery and morbidity, yet the lack of an internationally accepted definition and clinical management pathway for this condition suggest POI may be under-recognized as a clinical problem. The purpose of this survey was therefore to assess current attitudes of surgeons towards the clinical impact and management of POI. Telephone interviews were conducted with 230 surgeons from hospitals in the UK, France, Germany, Italy and Spain. Across Europe, there are differences in the terms surgeons use to refer to delayed recovery of gastrointestinal (GI) function and the symptoms, concerns and risks they associate with this condition. Furthermore, there is marked variation in the attitudes of European surgeons towards minimizing the risk of delayed recovery of GI function and in the strategies to manage POI. Additionally, some of the measures applied most commonly by European surgeons are in contrast to evidence in the literature indicating that they have no benefit for quicker resolution of GI function. The results suggest that there is a need for clearer definition of the factors that constitute POI, increased recognition of the impact of this condition and improved understanding of the most effective peri-/postoperative care for surgical patients.

Evaluation of a New m-Opiod Antagonist for the Management of Postoperative Ileus; Additional Phase II Study Results

Evaluation of a New m-Opiod Antagonist for the Management of Postoperative Ileus; Additional Phase II Study Results