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 28,200 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Major abdominal surgery, and also radical cystectomy, is followed by a delayed return of bowel function attributable to postoperative ileus (POI), which, in addition, stands out as one of the most frequent complications that causes increased length of stay (LOS). Some variability exists in the definition of POI since time to return of peristalsis and time to first passage of flatus, which are commonly referred to as indicators of bowel activity, have their own weaknesses, observer dependent and time dependent, among other variables. A number of causes have been recognized to induce or maintain the condition of ileus. Some among them are part of the perioperative period. The practices of mechanical bowel preparation (MBP) and of fasting before surgery have been challenged and can be safely abandoned. The perception of pain is an acknowledged promoter of POI; therefore, providing complete pain control constitutes the rationale in favor of administering anesthesia and analgesia combined, both in the form of concurrent general and epidural anesthesia (i.e., at the thoracic level, T9, T11), and represents the mainstay of intraoperative measures. Hypovolemia is also associated with an increased risk of POI. The use of nasogastric tubing (NGT) has been associated with increased pulmonary complications; moreover, bowel resection can be performed safely without postoperative NGT. Early postoperative provision of artificial nutrients has shown beneficial effects, both in the form of total parenteral and enteral nutrition (PEN, EN). We devised a perioperative care regimen, adopting a multimodality approach aimed at minimizing the effects of the above listed factors to ascertain if they could contribute to preventing or reducing POI and the complications associated with radical cystectomy and intestinal urinary diversion. In addition, we investigated the impact of early artificial nutrition, combining PEN and EN via a jejunal nutrition cannula. Time to return of bowel movements, time to reinstitution of a regular diet, presence and duration of POI, and incidence and nature of complications constituted the study end points. Of 143 consecutive patients, 107 who underwent radical cystectomy with intestinal urinary reconstruction were able to be evaluated for results and complications. The male to female ratio was 86:21, the mean age was 74 years, and more than two-third belonged to the American Society of Anesthesiologists categories II and III. Pathologic stages of disease were bladder confined in 48 patients, locally advanced in 33, and extravesical in 26. Urinary diversion with intestine consisted in the configuration of heterotopic reservoirs in 39 patients, orthotopic substitution in 38, and uretero-ileo-cutaneostomy in 30. Bowel movements returned after a median time of 2 days (range, 1-6), and the median time to reinstitution of a regular diet was 4 days (range, 3-9). POI beyond postoperative day 4 was observed in 17.7% of the patients. Overall, a total of 28 patients (26.1%) experienced complications, specifically, medical complications in 19 patients and surgical complications leading to relaparotomy in 11. The mortality rate was 3.7%. No effects were observed on postoperative protein depletion, despite the provision of early artificial nutrition. Our results suggest that a short median time of return of both peristalsis and flatus, and to regular diet resumption with a low incidence of POI, can be obtained in the majority of patients with a perioperative regimen aimed at reducing the effect of some of the causes associated with induction or maintenance of POI. Further studies of multimodality perioperative care plans, similar to that used in the present study, are required.
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PMID:Current perioperative management of radical cystectomy with intestinal urinary reconstruction for muscle-invasive bladder cancer and reduction of the incidence of postoperative ileus. 1796 14

The localization of opioid receptors and their endogenous peptide ligands within the gastrointestinal (GI) tract and their role in the coordination of propulsion and secretion underscores the importance of opioid receptors in the maintenance of GI homeostasis. The peripherally acting micro-opioid receptor antagonists alvimopan and methylnaltrexone (MNTX) are currently under investigation as therapeutic agents to treat the deleterious GI side effects associated with opioid administration. These compounds have demonstrated efficacy in numerous animal models of GI function, and clinical studies have revealed their efficacy in the treatment of postoperative ileus (POI) and opioid-induced bowel dysfunction. Preservation of opioid-mediated analgesia has been demonstrated for these compounds in both the preclinical and clinical settings. Future studies exploring the benefits of selective antagonism of the peripheral mu-opioid receptor in the treatment of other GI conditions may open new therapeutic opportunities for alvimopan and MNTX.
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PMID:The involvement of the mu-opioid receptor in gastrointestinal pathophysiology: therapeutic opportunities for antagonism at this receptor. 1802 96

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.
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PMID:Management of postoperative ileus. 1809 Aug 81

There is much variability regarding time to start of enteral nutrition in patients undergoing colorectal surgery. In many instances such patients are postoperatively maintained with nasogastric intubation with the aim of preventing complications such as dehiscence, evisceration or eventration. We examine the clinical evidence regarding nasogastric tube placement and early feeding with reference to the PubMed, Embase, and Cochrane databases.Ia and Ib evidence was obtained from meta-analyses and prospective randomized studies, where the systematic use of a gastric decompression catheter is advised against and initiation of early feeding for colorectal surgery is recommended. Fasting does not provide any benefit after gastrointestinal surgery, and the use of nasogastric tubes does not decrease postoperative complications. However, less invasive surgery and new advances in anesthesia and analgesia are contributing to a reduction in postoperative ileus.
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PMID:[Evidence of early oral feeding in colorectal surgery]. 1829 Jun 95

After major abdominal surgery, postoperative ileus is inevitable, and it has always been a challenge for the surgical team to shorten the duration of this period. Based on many clinical and basic reports that affirm the effect on the recovery of gastrointestinal motility, epidural analgesia has been used widely to promote recovery from postoperative ileus. Different techniques have been used to measure gastrointestinal motility in laboratory and clinical investigations. Many of the techniques used in clinical investigations of gastrointestinal motility are controversial because they are subjective. In the laboratory strain gauge force transducer (SGT) can provide objective data on gastrointestinal motility. Nevertheless the significance of SGT in the clinical setting is yet to be confirmed. Therefore in this review we examine both clinical and laboratory outcomes of epidural analgesia on gastrointestinal motility to present the possibility for the development of gastrointestinal motility research with SGTs. We suggest that further investigation using SGTs may lead to the development of objective methods that allow objective assessment of post-surgical gastrointestinal function.
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PMID:Epidural analgesia and gastrointestinal motility after open abdominal surgery--a review. 1855 53

This article reviews techniques currently used to prevent or reduce the duration of postoperative ileus (POI), which is considered an undesirable stress response to major abdominal surgery that leads to discomfort, morbidity and prolonged hospital stay. In several randomized studies, a number of techniques have been demonstrated to reduce the occurrence and/or duration of POI: thoracic epidural analgesia with local anesthetics, peripheral opioid antagonists, laxatives, chewing gum, intravenous and incisional local anesthetics, and avoidance of routine nasogastric intubation and fluid excess. Early institution of oral feeding and laparoscopic surgery might also be effective, but there is less clear evidence available to support their use. When some of these techniques are combined as part of the concept of multimodal postoperative rehabilitation (fast-track surgery), the duration of POI after open or laparoscopic abdominal surgery can be reduced to 24-48 h in most patients. There is a need for data on the effect of these techniques on POI when applied to major upper abdominal surgeries and emergency abdominal operations (e.g. trauma, peritonitis, etc.).
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PMID:Postoperative ileus--an update on preventive techniques. 1869 4

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.
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PMID:Alvimopan. 1877 22

Objective Evidence regarding perioperative care in colorectal surgery has recently increased, leading to changes in classical clinical procedures that make the perioperative period safer and shorter. This survey aimed to evaluate the opinions of Spanish colorectal surgeons on the perioperative management of their patients. Method Emailed surveys submitted to the members of Spanish Coloproctological Associations. Results One hundred and thirty-one (31.7%) of the 413 members participated in the study and responded thus: 21% use clinical pathways and 8% use fast track (FT); 36% use epidural analgesia in colonic surgery and 57% in rectal; 40% use warm air and 23% warm fluids to maintain intraoperative normothermia; 53% prescribe >/= 3000 ml. of iv fluids on the first postoperative day and 6.2%</= 2000 ml; 43% never use nasogastric tubes. Oral intake was initiated by 23.5% on the first day, and by 50% when peristalsis began, with an earlier tendency in laparoscopic surgery; 43% believed oral intake reduces ileus, but 12% considered it dangerous. Board accreditation and experience in Coloproctology were significantly associated with a lesser use of nasogastric tubes and earlier feeding. Sixty-nine per cent considered FT reduces postoperative stay and 44% thought that it minimizes complications. Conclusion Spanish surgeons maintain a classical procedural policy, but show tendencies towards optimizing patients' care.
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PMID:Perioperative care in colorectal surgery: current practice patterns and opinions. 1917 33

Postoperative Ileus (POI) is a frequent, frustrating occurrence for patients and surgeons after abdominal surgery. Despite significant research investigating how to reduce this multi-factorial phenomenon, a single strategy has not been shown to reduce POI's significant effects on length of stay (LOS) and hospital costs. Perhaps the most significant cause of POI is the use of narcotics for analgesia. Strategies that target inflammation and pain reduction such as NSAID use, epidural analgesia, and laparoscopic techniques will reduce POI but are accompanied by a simultaneous reduction in opioid use. Pharmacologic means of stimulating gut motility have not shown a positive effect, and the routine use of nasogastric tubes only increases morbidity. Recent multi-site phase III trials with alvimopan, a peripherally acting mu-antagonist, have shown significant reductions in POI and LOS by 12 and 16 hours, respectively, by blunting the effects of narcotics on gut motility while sparing centrally mediated analgesia. Use of alvimopan, along with a multi-modal postoperative treatment plan involving early ambulation, feeding, and avoiding nasogastric tubes, will likely be the crux of POI treatment and prevention.
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PMID:Postoperative ileus: strategies for reduction. 1920 73

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.
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PMID:Management of postoperative ileus: focus on alvimopan. 1920 78


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