Return Of Bowel Function Research Articles

V-041 ENTEROCUTANEOUS FISTULA TAKEDOWN AND VENTRAL HERNIA REPAIR WITH PREPERITONEAL MESH

Abstract In this video, we present a 48-year-old otherwise healthy man with a history of perforated appendicitis status post exploratory laparotomy and appendectomy, complicated by an intraabdominal abscess requiring re-exploration and subsequent midline wound dehiscence, incisional ventral hernia, and enterocutaneous fistula managed with a drain. Plastic surgery performed a split thickness skin graft of his midline wound, and his drain was kept in place until surgery. The patient was taken to the operating room for a takedown of his enterocutaneous fistula and an open repair of his incisional ventral hernia. We entered the abdomen in the midline, far away from the fistula. After lysing omental and bowel adhesions, we identified the patient's drain entering the small bowel and exiting about 10 cm distally. We removed the drain from the small bowel and performed a small bowel resection, including the entry and exit points of the drain, and a stapled side-to-side antiperistaltic anastomosis. Preperitoneal planes were developed bilaterally, and the peritoneum was rearranged over the bowel and partially closed to the omentum. We placed a biologic mesh into the preperitoneal plane and secured it in place with transfascial sutures. We then performed a multilayer closure of the fascia and dermis and an incisional negative pressure dressing was placed over the wound. The patient was discharged on postoperative day 4 after tolerating a regular diet and having full return of bowel function. In summary, this video demonstrates several important operative techniques in our approach to this complex case.

Surgical considerations and outcomes of minimally invasive approaches for gastric cancer resection.

Despite high mortality rates from gastric cancer, surgical management remains critical for curative potential. Optimal outcomes of gastric cancer resection depend on a multitude of variables, including the extent of resection, scope of lymphadenectomy, method of reconstruction, and potential for a minimally invasive approach. Laparoscopic gastrectomy, compared with open gastrectomy, has been analyzed in numerous randomized control trials. Generally, those trials demonstrated statistically similar postoperative complication rates, mortality, and oncologic outcomes between the two approaches. Although laparoscopic gastrectomy requires longer operative times, significant improvements in estimated blood loss, postoperative length of stay, and return of bowel function have been noted in patients who undergo laparoscopic gastrectomy. These short-term benefits, along with equivalent oncologic results, have influenced national guidelines in both Eastern and Western countries to recommend laparoscopy, especially for early stage disease. Although robotic gastrectomy has not been as widely validated in effective trials, studies have reported equivalent oncologic outcomes and similar or improved postoperative complication and recovery rates after robotic gastrectomy compared with open gastrectomy. Comparing the two minimally invasive gastrectomy approaches, robotic surgery was associated with improved estimated blood loss, incidence of pancreatic sequela, and lymph node harvests in some studies, whereas laparoscopy resulted in lower operative times and hospital costs. Ultimately, when applying outcomes from the literature to clinical patient care decisions, it is imperative to recognize these studies' range of inclusion criteria, delineating between patients originating from Eastern or Western countries, the use of neoadjuvant chemotherapy, the volume of surgeon experience, and the extent of gastrectomy, among others.

Auto-diuresis Predicts Return of Bowel Function.

Feeding a ventral hernia repair (VHR) patient before the return of bowel function (ROBF) can lead to distention and emesis. Many patients spontaneously diurese after surgery. We hypothesized that this auto-diuresis would signal ROBF. A total of 395 patients who underwent open, laparoscopic, or mixed VHR were evaluated for correlation between fluid status and ROBF or discharge. ROBF within 24 hours and discharge within 24 hours or 48 hours were used as outcome measures. Patients remained an average 3.59 days after surgery in the hospital and the average ROBF was on day 2.99. The first shift of ≥700mL of urine predicted ROBF ( P =0.03) and discharge ( P =0.04) within 24 hours. The first shift output of ≥500mL predicted discharge within 48 hours ( P =0.02). Auto-diuresis after surgery is correlated to ROBF and discharge. Accurate fluid measurement can predict bowel function and allow early diet and discharge.

Robotic-Assisted Laparoscopic Sigmoidectomy with Transrectal Specimen Extraction for Recurrent Diverticulitis

Natural orifice specimen extraction is a surgical technique that is defined as the removal of a surgical specimen from a natural orifice with intracorporeal anastomosis. Natural orifice specimen extraction is defined by the site of extraction and has been performed via the vagina, anal canal, rectum, colon, and mouth. The primary benefit of this technique is reduced trauma at the access point due to avoidance of mini laparotomy, used to facilitate specimen extraction in conventional laparoscopy. This technique has been associated with less postoperative pain, lower analgesic requirement, faster return of bowel function, and fewer incisional hernias, as well as an improved cosmetic result. Use of the robotic platform allows for deep pelvic dissection, which is challenging to impossible with laparoscopic instruments. Here, we report a case of recurrent diverticulitis in the setting of complex abdominal surgical history managed by robotic-assisted laparoscopic sigmoidectomy with transrectal specimen extraction.

Cost-Effectiveness of Open Repair of Abdominal Aortic Aneurysms with a Novel Perioperative Protocol

In 2015, a novel perioperative protocol (nPOP), comprising of 19 evidence-based interventions, was adopted as a standard practice for open repair of abdominal aortic aneurysms (AAA) at the Humanitas Clinical and Research Center (Milan, Italy). Its implementation translated into lower complication rates, faster ambulation and return of bowel function, better nausea/vomiting and pain control, and, consequently, a shorter length of hospital stay. Because value of a patient's care cycle can be defined as clinical outcomes relative to costs, we aimed to analyze the cost-effectiveness of nPOP compared to the previously implemented protocols. Three groups were identified and retrospectively analyzed: (A) 66 patients (September 2007 to March 2009) treated according to the traditional protocol; (B) 225 patients (April 2009 to March 2015) treated in line with a transitional protocol, incorporating 5 perioperative interventions; and (C) 103 patients (April 2015 to February 2019) treated according to nPOP. For each group a monetary value of required clinical resources and the actual total cost per patient from admission to discharge were determined. The following were analyzed (including nurse and anesthesiologist time): diagnostic tests, medications, materials, operating time, surgical team time, blood transfusion, ward stay, and intensive care unit stay. Two indicators of effectiveness were determined based on the postoperative outcomes: complication-free incidents and relative shortening of hospitalization time. A cost (€) of an improvement in effectiveness (%) was calculated. Alongside enhancement of clinical outcomes, nPOP constituted the cheapest approach. It consumed the least human and material resources, resulting in the direct reduction in the overall clinical cost per patient. The length-of-stay variable provided the largest reduction in total costs. The actual total clinical cost per patient in Group C was 26% lower than in Group A (4,437€ vs. 6,005€) and 39% lower than in Group B (4,437€ vs. 7,305€). Every unit of enhancement of clinical outcomes was 2.43 times more expensive for the traditional protocol and 2.23 times more costly for the transitional protocol compared to nPOP, making it the most cost-effective. The nPOP for AAA open repair is not inferior to other perioperative protocols while allowing for efficient utilization of limited hospital resources, thus creating a high social value. The proposed methods for cost-effectiveness analysis are easily reproducible and therefore can be applied in future projects ranging from a micro- to a macro-economic scale.

How does the ERAS protocol work in patients who underwent cesarean section? (HERMES study).

To assess the effect of the enhanced recovery after surgery (ERAS) protocol for cesarean deliveries (CD) on postoperative outcomes. This multicenter prospective cohort study was conducted in six different centers between September 2020 and March 2021 and involved women who underwent either planned or unplanned CD. The primary outcome was time to the first passage of flatus following CD. Secondary outcomes included postoperative pain score, postoperative complications, and patient satisfaction. The protocol included early postoperative oral intake of ice cream and coffee, multimodal analgesia, antiemetic medications, and early ambulation. A total of 448 patients were included. The median time to the first passage of flatus was 10h in the Hermes group and 18 hours in the control group (P< 0.001). Postoperative visual analog scale scores were significantly higher in the control group. Patient satisfaction scores and the frequency of postoperative complications did not differ between the groups (P= 0.08, P= 0.604, respectively). The ERAS protocol, including early serving of ice cream and coffee in the early postoperative period, enabled early discharge and a faster return of bowel function. Implementation of the ERAS protocol for patients who underwent planned and unplanned CD appeared to be safe and effective.

How Abdominal Irrigation During Cesarean Delivery Affects Gastrointestinal Functions and Short-term Maternal Morbidities: A Randomized Controlled Study.

Objective:This study aimed to investigate the effectiveness of intraabdominal irrigation with saline on postoperative gastrointestinal functions and short-term complications in patients who underwent cesarean section under general anesthesia.Methods:This prospective randomized controlled clinical trial was conducted between March 2022 and May 2022 and included 60 patients who underwent elective cesarean. The participants were randomized into two groups: abdominal irrigation (n=30) and control group (n=30). Participants undergo a standard cesarean procedure, and general anesthesia was preferred. The patients were questioned regarding nausea, vomiting, highest pain scores, time of flatus, and stool passage during the postoperative period.Results:Although no significant differences were found between the two groups (p>0.05), the return of bowel functions, i.e., passage of flatus and stool, occurred in a shorter period in the irrigation group (19.53 and 34.63 versus 16.73 and 33.7). The postoperative visual analog scale (VAS) scores of the two groups were comparable; VAS score of 4-6 was the sole difference when comparing both groups. Although postoperative vomiting was more common in the control group, no significant difference in postoperative vomiting, postoperative nausea, and postoperative antiemetic need was found between the two groups (p>0.05).Conclusions:The results revealed that intraoperative abdominal irrigation did not affect gastrointestinal functions and short-term maternal morbidity and did not provide additional benefits.

Three cases utilizing the Hidden Incision Endoscopic Surgery approach to port placement during penile inversion vaginoplasty utilizing a peritoneal flap

Younger transgender patients undergoing penile inversion vaginoplasty (PIV) after pubertal suppression often require modified techniques to augment neovaginal tissue. Peritoneal flap vaginoplasty (PFV) is a well-established technique for improving neovaginal depth. Utilizing a Hidden Incision Endoscopic Surgery (HIdES) approach to port placement improves cosmetic outcomes of this identity-affirming procedure. This video shows the efficacy of the HIdES port placement configuration on the daVinci robot for peritoneal flap creation and closure during PIV using the modified laparoscopic Davydov procedure. Three young adult transgender females who had not undergone laser hair removal/epilation underwent PIV with robotic PFV utilizing HIdES port placement. The anterior superior iliac spine (ASIS) was demarcated bilaterally, and ports were placed at or below these lines. Two surgical teams, external genitoplasty and internal peritoneal flap closure via daVinci Xi robot, worked simultaneously. All patients underwent successful robotic assisted PIV with HIdES port placement. All patients had similar postoperative courses of return of bowel function with flatus on postoperative day (POD) 2, vaginal dressing, urethral catheter removal, and initiation of vaginal dilation on POD 5-6, and hospital discharge between POD 5-8. We present our initial experience with robotic/laparoscopic PFV using a hidden incision approach. This technique allows for excellent neovaginal depth with improved abdominal wound aesthetics.

The effect of intravenous infusion of dexmedetomidine versus lidocaine as an analgesic adjuvant to balanced general anesthesia and enhanced recovery after abdominal surgery

BackgroundIntravenous dexmedetomidine and lidocaine have been shown to decrease perioperative surgical pain and analgesic consumption and facilitate the return of bowel function, decreasing post-operative hospitalization.ResultsOn the first post-operative day, VAS score and total consumption of narcotics were statistically insignificant between the two groups. Heart rate and mean arterial pressure were significantly lower in the dexmedetomidine group than in the Lidocaine group all through the surgery (p value < 0.001). Post-operative nausea and vomiting were statistically higher in group D than in group L (p value 0.001).ConclusionsThe administration of either lidocaine or dexmedetomidine did not show superiority in post-operative analgesia or perioperative narcotics consumption. However, lidocaine infusion showed less drug-related side effects from the aspect of intraoperative hemodynamics stability, post-operative ileus, nausea, and vomiting.

Experiece of laparoscopic appendicectomy versus open appendicectomy in Babylon

To compare laparoscopic appendectomies versus open and to evaluate the level of efficacy of both surgical approach . The predictor variables explored in this study were:age,gender,ultrasound procedure,operative time,post operative stay, number of hours required for the return of bowel function, use of narcotic analgesia ,any postoperative complications and regaining of routine activities: A total of 119 patients clinical records were reviewed, of these 22 patients had had laparoscopic appendectomies and 97 had open appendectomies.All the operations had done by a general surgeons in Babylon.The mean operative time in minutes was relatively shorter for open appendectomy (48) compared to laparoscopic appendectomy (84).The average time for the return of bowel movement was remarkable less for laparoscopic appendectomy (12) hours versus open appendectomy(24) hours.the mean post operative stay in hours was relatively shorter for laparoscopic appendectomy (18)compared to open appendectomy (30).Hence our study found that laparoscopic appendectomy is a safe and effective procedure for the removal of appendix over open appendectomy.

COMPARATIVE STUDY OF ERAS PROTOCOL WITH CONVENTIONAL PROTOCOL FOR GYNECOLOGICAL SURGERY

Background Enhanced Recovery After Surgery (ERAS) have been proposed to improve the quality of in-hospital care by reducing functional capacity loss and fasten the recovery in gynecological patients. The aim of this studyObjective was to compare the ERAS protocol with conventional protocol in post-operative outcome following gynecological surgery. A prospective, comparative study was done at Geetanjali medical college and Hospital, UdaipurMethod between January 2020 to January 2021. 40 patients, each in group of ERAS and Conventional protocol group having patients of elective gynecological surgery, were compared for demographic profile, Pain assessment, Time of oral intake, bowel bladder function, hospital stay and post-operative complication. In this study, Mean VASResults postoperatively in ERAS group was much lower than conventional group (p &lt; 0.001). In ERAS and conventional group, oral intake was 7.30 ± 1.49 hours, and 24 ± 0.001 hours respectively (p &lt;0.01). The mean de-catheterization time was 18.60 ± 1.03 hours in ERAS group as compared to 45.90 ± 2.07 hours in conventional group(p &lt;0.01). The length of hospital stay for ERAS group patients were very low compared to Conventional group. There was no significant difference in both group regarding age, weight, height, BMI and parity, post-operative complications and readmission rates. ERAS is helpful in reducing the length of hospitalization, early return of bowel function, cost effectiveConclusion with very fewer complications compared to conventional group. The properly implemented ERAS protocol leads to faster recovery and discharge with improved patient satisfaction and quality of life.

Naloxegol versus Alvimopan for Enhancing Postoperative Recovery following Radical Cystectomy for Bladder Cancer.

µ-Opioid-receptor antagonists are a standard component of enhanced recovery after surgery (ERAS) pathways following radical cystectomy (RC) as they reduce ileus and shorten length of stay (LOS). Prior studies have used alvimopan; however, naloxegol is a less expensive medication in the same class. We compared differences in postoperative outcomes between patients receiving alvimopan or naloxegol following RC. We retrospectively reviewed all patients undergoing RC over 20 months at an academic center during which standard practice transitioned from using alvimopan to naloxegol, while maintaining all other components of our ERAS pathway. We utilized bivariate comparisons as well as negative binomial and logistic regression to compare return of bowel function, rates of ileus and LOS following RC. Of 117 eligible patients, 59 (50%) received alvimopan and 58 (50%) received naloxegol. There were no differences in baseline clinical, demographic or perioperative factors. Median postoperative LOS was 6 days in each group (p=0.3). Time to flatus (2 versus 2 days, p=0.2) and ileus (14% versus 17%, p=0.6) were similar between the alvimopan and naloxegol groups, respectively. In multivariable models controlling for patient and surgical factors, µ-opioid antagonist agent was associated with neither LOS nor ileus. Cost difference was -$344.20/day, equivalent to a $2,065.20 savings over a 6-day hospital stay with naloxegol. In patients undergoing RC managed with a standard ERAS pathway, there were no differences in postoperative recovery based on the use of alvimopan versus naloxegol. Substitution of naloxegol for alvimopan may allow for significant cost savings without compromising outcomes.

Effect of perioperative lignocaine infusion on postoperative pain relief for laparoscopic intraperitoneal onlay mesh repair: A randomized controlled study.

The focus on enhanced recovery after surgery (ERAS) and opioid-free anesthesia has renewed interest in use of lignocaine. We evaluated postoperative pain relief following intravenous (IV) lignocaine administration in patients undergoing laparoscopic intraperitoneal onlay mesh repair (IPOM). Seventy patients were randomized into two groups. Group L patients were administered IV lignocaine infusion (1.5mg/kg) at induction of anesthesia followed by infusion (1.5mg/kg/h), until 1hour in the post-anesthesia care unit (PACU). Group P patients received equal volumes of normal saline IV infusion. We recorded hemodynamics, perioperative analgesic consumption, postoperative visual analog scores (VAS), incidence of postoperative nausea and vomiting (PONV), bowel function, patient satisfaction and length of hospital stay (LOS). The hemodynamics in both groups were maintained. Group L had lower VAS scores as compared to Group P (P < .05). Intraoperative fentanyl consumption in Group L was significantly less than Group P (P=.029). Group L patients scored lower on the Likert scale in comparison to the patients of Group P at 0hour (P=.013). Recovery of bowel function as assessed by time to pass first flatus was significantly shortened by IV lignocaine (P=.001). The perioperative administration of IV lignocaine resulted in decreased postoperative analgesic requirement and greater patient satisfaction scores. Perioperative IV lignocaine infusion provided good pain relief, hemodynamic stability and decreased perioperative analgesic consumption. PONV incidence decreased along with an early return of bowel function, reduced LOS and improved patient satisfaction in patients undergoing laparoscopic IPOM surgery.

Laparoscopic Appendectomy VS Open Appendectomy at Jeddah National Hospital Saudi Arabia; A Comparative Study

Objective: To compare the laparoscopic appendectomy (LA) with open appendectomy (OA) in terms of operative time, complications, and hospital stay. Patients and Methods: This comparative study was done at Jeddah National Hospital, KSA. All the patients aged more than 12 years, both genders, and those who were admitted with appendicitis to the surgical department and underwent surgical treatment were included. The study duration was one year, from November 2019 to October 2020. All the patients were divided into two groups. Patients who underwent laparoscopic appendectomies were put in LA group, while those who underwent open appendectomies were kept in OA group. All the patients were observed during hospital stays and comparative treatment outcomes were observed in terms of the pain, number of hours required for the return of bowel function, operative time, infection and hospital stays. A study proforma was used for the data collection and SPSS version 26 was used for the data analysis. Results: A total of 100 cases were comparatively studied, and the overall age of the patients was 33.34+7.23 years. Males were dominant as compared to females. Average operating time was lower in LA group as 37.11+8.41 minutes, compared to the OA group 47.45+4.34 minutes (p-0.001). The average post-operative hospital stay was 1.88+0.62 days in LA group, compared to the OA group 2.14+0.90 days, without a significant difference (p-0.098). Post operative infection was statistically insignificant in both groups as one case in the LA group and in cases of the OA group (p-558). Conversion to an open procedure was required in one case with extensive cecal adhesions and retrocecal gangrenous appendicitis with local peritonitis. 70% patients of LA group, returned to their normal routine life within 10 days and the remaining started doing their normal activities within 15 days, while in the OA group, 60% of patients returned to normal activity and 40% returned to work after 20 days. No mortality was found in either group. Conclusion: Laparoscopic appendectomy was observed to be a time-saving procedure, which depends on skills, patient selection, and availability of the laparoscope. It is safe when compared to open appendectomy. It shortens the hospital stay, allows for an earlier return to oral feeding, normal routine work, and results in fewer post-operative complications. Keywords: Laparoscopic, Open, Appendectomy, Hospital stay, pain, infection

Assessing outcomes in laparoscopic vs open surgical management of adhesive small bowel obstruction.

Small bowel obstruction is typically managed nonoperatively; however, refractory small bowel obstructions or closed loop obstructions necessitate operative intervention. Traditionally, laparotomy has long been the standard operative intervention for lysis of adhesions of small bowel obstructions. But as surgeons become more comfortable with minimally invasive techniques, laparoscopy has become a widely accepted intervention for small bowel obstructions. The objective of this study was to compare the outcomes of laparoscopy to open surgery in the operative management of small bowel obstruction. This is a retrospective analysis of operative small bowel obstruction cases at a single academic medical center from June 2016 to December 2019. Data were obtained from billing data and electronic medical record for patients with primary diagnosis of small bowel obstruction. Postoperative outcomes between the laparoscopic and open intervention groups were compared. The primary outcome was time to return of bowel function. Secondary outcomes included length of stay, 30-day mortality, 30-day readmission, VTE, and reoperation rate. The cohort consisted of a total of 279 patients with 170 (61%) and 109 (39%) patients in the open and laparoscopic groups, respectively. Patients undergoing laparoscopic intervention had overall shorter median return of bowel function (4 vs 6days, p = 0.001) and median length of stay (8 vs 13days, p = 0.001). When stratifying for bowel resection, patients in the laparoscopic group had shorter return of bowel function (5.5 vs 7days, p = 0.06) and shorter overall length of stay (10 vs 16days, p < 0.002). Patients in the laparoscopic group who did not undergo bowel resection had an overall shorter median return of bowel function (3 vs 5days, p < 0.0009) and length of stay (7 vs 10days, p < 0.006). When comparing surgeons who performed greater than 40% cases laparoscopically to those with fewer than 40%, there was no difference in patient characteristics. There was no significant difference in return of bowel function, length of stay, post-operative mortality, or re-admission laparoscopic preferred or open preferred surgeons. Laparoscopic intervention for the operative management of small bowel obstruction may provide superior clinical outcomes, shorter return of bowel function and length of stay compared to open operation, but patient selection for laparoscopic intervention is based on surgeon preference rather than patient characteristics.

Comparison of Ultrasound-Guided Caudal Epidural Blocks and Spinal Anesthesia for Anorectal Surgery: A Randomized Controlled Trial.

IntroductionThe aim of this study is to observe the effect of spinal anesthesia (SA) and ultrasound-guided caudal epidural blocks (CEB) on perioperative satisfaction in patients undergoing anorectal surgery.MethodsA group of 106 patients were randomly allocated to receive either SA (the SA group) or CEB (the CEB group), and 11 patients were excluded. Finally, 95 patients were left, with 48 in the SA group and 47 in the CEB group for data analysis. The primary endpoint was patient satisfaction with the quality of their anesthetic technique. The secondary outcome measures included postoperative pain at 2, 4, 8, 16, 24, and 48 h after surgery at rest, time to first analgesic request, analgesia requirements, incidence of phantom limb syndrome (PLS), time until return of bowel function, time to ambulation, incidence of postoperative nausea and vomiting (PONV), intraoperative mean arterial pressure (MAP) reduction > 20% from baseline, and surgeon satisfaction.ResultsA significantly lower proportion of patients in the SA group was highly satisfied with the quality of their anesthetic technique compared with the CEB group (20.8% versus 68.1%). NRS scores at rest were significantly lower at 4, 8, 16, and 24 h after surgery in the CEB group compared with the SA group. The time to first analgesic request was significantly earlier for patients in the SA group compared with patients in the CEB group. Analgesia requirements, the incidence of PLS, the incidence of PONV, and intraoperative MAP reduction > 20% from baseline were significantly decreased in the CEB group. There were no significant differences between the groups in time until return of bowel function, surgeon satisfaction, or time to ambulation.ConclusionsUltrasound-guided caudal epidural blocks have higher patient satisfaction compared with spinal anesthesia.Trial RegistrationThis study was registered in the Chinese Clinical Trial Registry (ChiCTR 2000041026) on 06/12/2020.

MP39-09 COMPARISON OF ALVIMOPAN VERSUS NALOXEGOL FOR ENHANCING POSTOPERATIVE RECOVERY FOLLOWING RADICAL CYSTECTOMY FOR BLADDER CANCER

You have accessJournal of UrologyCME1 May 2022MP39-09 COMPARISON OF ALVIMOPAN VERSUS NALOXEGOL FOR ENHANCING POSTOPERATIVE RECOVERY FOLLOWING RADICAL CYSTECTOMY FOR BLADDER CANCER Peter Kirk, Austin Wang, Dima Raskolnikov, Sarah Psutka, George Schade, John Gore, Yaw Nyame, Janet Kelly, and Jonathan Wright Peter KirkPeter Kirk More articles by this author , Austin WangAustin Wang More articles by this author , Dima RaskolnikovDima Raskolnikov More articles by this author , Sarah PsutkaSarah Psutka More articles by this author , George SchadeGeorge Schade More articles by this author , John GoreJohn Gore More articles by this author , Yaw NyameYaw Nyame More articles by this author , Janet KellyJanet Kelly More articles by this author , and Jonathan WrightJonathan Wright More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002599.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Opioid-receptor antagonists reduce the occurrence of postoperative ileus and shorten length of stay following radical cystectomy (RC), and are a standard component of enhanced recovery after surgery (ERAS) pathways. Although most prior data have studied the use of alvimopan for this indication, naloxegol is a less expensive alternative within the same medication class. We compared differences in postoperative outcomes between patients receiving alvimopan and naloxegol following RC. METHODS: We retrospectively reviewed all patients undergoing RC (open and robotic) and urinary diversion for bladder cancer at an urban, academic cancer center during which the standard practice transitioned from alvimopan to naloxegol without any other changes to our ERAS pathway (November 2019 through July 2021). We utilized bivariate comparisons as well as negative binomial and logistic regression to compare return of bowel function, rates of ileus, and length of stay (LOS) following RC. RESULTS: There were 86 patients eligible for inclusion, of whom 52 (60.5%) received alvimopan and 34 (39.5%) received naloxegol. There were no significant differences in baseline clinical or demographic characteristics, nor in perioperative factors (Table). Median postoperative LOS was six days with no significant differences between medication groups. There were also no significant differences between alvimopan and naloxegol in time to return of bowel function (3 versus 2 days to flatus, respectively, p =0.09) or rates of postoperative ileus (13 versus 24 percent, respectively, p =0.26). In multivariable models controlling for patient and surgical factors, choice of medication was not a significant predictor of LOS or ileus. Mean cost difference between alvimopan and naloxegol was -$328.22 per day in favor of naloxegol, equivalent to a reduction of $1,969.32 over a six-day hospital stay. CONCLUSIONS: In patients undergoing RC, there were no significant differences in postoperative recovery based on the use of alvimopan versus naloxegol. Substitution of naloxegol for alvimopan may allow for significant cost savings without compromising outcomes. Source of Funding: This work was supported by intramural funding through the University of Washington Urology Department © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e668 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Peter Kirk More articles by this author Austin Wang More articles by this author Dima Raskolnikov More articles by this author Sarah Psutka More articles by this author George Schade More articles by this author John Gore More articles by this author Yaw Nyame More articles by this author Janet Kelly More articles by this author Jonathan Wright More articles by this author Expand All Advertisement PDF DownloadLoading ...

Consumption of a multi-deficient diet causes dynamic changes in the intestinal morphofunctional barrier, body composition and impaired physical development in post-weaning mice.

Few studies have focused on nutrient-deficient diets and associated pathobiological dynamics of body composition and intestinal barrier function. This study evaluated the impact of a nutrient-deficient diet on physical development and intestinal morphofunctional barrier in mice. C57BL/6 (21 days of age) mice were fed a Northeastern Brazil regional basic diet (RBD) or a control diet for 21 d. The animals were subjected to bioimpedance analysis, lactulose test, morphometric analysis and quantitative reverse transcription-PCR to evaluate tight junctions and intestinal transporters. RBD feeding significantly reduced weight (P < 0·05) from day 5, weight gain from day 3 and tail length from day 14. The intake of RBD reduced total body water, extracellular fluid, fat mass and fat-free mass from day 7 (P < 0·05). RBD induced changes in the jejunum, with an increase in the villus:crypt ratio on day 7, followed by reduction on days 14 and 21 (P < 0·05). Lactulose:mannitol ratio increased on day 14 (P < 0·05). Changes in intestinal barrier function on day 14 were associated with reductions in claudin-1 and occludin, and on day 21, there was a reduction in the levels of claudin-2 and occludin. SGLT-1 levels decreased on day 21. RBD compromises body composition and physical development with dynamic changes in intestinal barrier morphofunctional. RBD is associated with damage to intestinal permeability, reduced levels of claudin-1 and occludin transcripts and return of bowel function in a chronic period.

Acupuncture and Postoperative Pain Reduction.

Acupuncture is an analgesic technique that has long been utilized in Eastern medicine. In recent times, various acupuncture techniques have been used in integrated pain management approaches in Western medicine. It has even been adopted as an analgesic method in surgical patients. Currently, no review exists regarding various acupuncture techniques used in perioperative pain management and data describing the utility of these techniques. This paper synthesizes the latest literature regarding the role of acupuncture in perioperative pain management. The authors sought to describe various acupuncture modalities used to help manage surgical pain and synthesize the current body of literature to help readers make informed judgements on the topic. Patients undergoing abdominal, spine/neuro, and gynecologic pelvic surgery generally benefit from acupuncture. Out of the various acupuncture techniques, electroacupuncture, transcutaneous electric acupoint stimulation, and traditional total body acupuncture seem to be most promising as adjuncts to multimodal perioperative analgesia. Benefits include improved analgesia and/or reduced narcotic requirements, decrease in PONV, and shorter time to return of bowel function. Acupuncture is a low-risk method that has the potential to enhance perioperative analgesia, decrease opioid requirement, and reduce unwanted side effects of anesthesia, surgery, and opioid administration such as nausea/vomiting. Given the variety of patient populations, various acupuncture techniques, and small patient populations for most current studies; it remains difficult to determine which acupuncture method would most benefit specific patients. Future studies with more robust sample sizes and prospective comparison on acupuncture technique would help better characterize acupuncture's role in perioperative pain management.

Ultrasound-guided versus laparoscopic-guided subcostal transversus abdominis plane (TAP) block versus No TAP block in laparoscopic cholecystectomy; a randomized double-blind controlled trial

BackgroundTransversus abdominis plane (TAP) block is an effective modality for the control of immediate postoperative pain. The present randomized trial aimed to assess the efficacy of ultrasound-guided subcostal TAP (USTAP) and laparoscopic subcostal TAP (LSTAP) block as compared to standard care without TAP block after laparoscopic cholecystectomy. MethodsThis was a prospective, randomized, controlled trial on patients who underwent laparoscopic cholecystectomy. Patients were equally randomized to one of three groups: USTAP, LSTAP, and control group (no TAP block). The main outcome measures were pain scores and analgesic consumption within the first 24 h postoperatively, postoperative nausea and vomiting (PONV), time to ambulation, time to first flatus, and adverse effects of TAP block. ResultsThe trial included 110 patients (90% females) with a mean age of 40.9 ± 11.7 years. Both USTAP and LSTAP block groups were associated with significantly lower pain scores at 2, 6, 12, and 24 h postoperatively, lower cumulative dose of paracetamol, less PONV, and shorter time to flatus than the control group. USTAP and LSTAP block were associated with similar pain scores at all time points, similar analgesic requirements, a similar incidence of PONV, and comparable time to first ambulation and time to first flatus. No adverse effects related to TAP block were recorded. ConclusionsTAP block is a safe and effective method for pain control and improving recovery after laparoscopic cholecystectomy. Both USTAP and LSTAP blocks were equally effective in terms of pain relief, analgesic requirements, PONV, return of bowel function, and time to ambulation.