Alvimopan (entereg) for the management of postoperative ileus in patients undergoing bowel resection. Reduction of Postoperative Ileus by Early Enteral Nutrition in Patients Undergoing Major Rectal Surgery: Prospective, Randomized, Controlled Trial The duration of postoperative ileus after elective colectomy is correlated to surgical specialization Early Feeding and the Incidence of Gastrointestinal Symptoms After Major Gynecologic Surgery Management of postoperative ileus: focus on alvimopan Prospective multicentre randomised controlled trial of early enteral nutrition for patients undergoing major upper gastrointestinal surgical resection. Phase III Trial of Alvimopan, a Novel, Peripherally Acting, Mu Opioid Antagonist, for Postoperative Ileus After Major Abdominal Surgery Goal-directed Fluid Therapy Does Not Reduce Primary Postoperative Ileus after Elective Laparoscopic Colorectal Surgery: A Randomized Controlled Trial Economic burden of postoperative ileus associated with colectomy in the United States. Effects of chewing gum against postoperative ileus after pancreaticoduodenectomy – a randomized controlled trial Does metoclopramide reduce the length of ileus after colorectal surgery? Effect of adding ketorolac to intravenous morphine patient‐controlled analgesia on bowel function in colorectal surgery patients – a prospective, randomized, double‐blind study Gastrointestinal tract recovery in patients undergoing bowel resection: results of a randomized trial of alvimopan and placebo with a standardized accelerated postoperative care pathway. Metoclopramide role in preventing ileus after cesarean, a clinical trial The future of fast‐track surgery The postoperative clinical outcomes and safety of early enteral nutrition in operated gastric cancer patients. A clinical pathway to accelerate recovery after colonic resection. A Characterization of Factors Determining Postoperative Ileus After Laparoscopic Colectomy Enables the Generation of a Novel Predictive Score Efficacy of metoclopramide in postoperative ileus after exploratory laparotomy. Randomized clinical trial of the impact of early enteral feeding on postoperative ileus and recovery The Effects of Metoclopramide on Postoperative Ileus A Randomized Double‐blind Study Effect of gum chewing on reducing postoperative ileus and recovery after colorectal surgery: A randomised controlled trial. A double-blind randomized controlled clinical trial to assess the effect of Doppler optimized intraoperative fluid management on outcome following radical cystectomy.
Postoperative ileus ( POI ) after open abdominal surgery and bowel resection can lead to significant patient discomfort , morbidity , and prolonged length of stay in the hospital . Several factors have been implicated in the pathophysiology of POI , including surgical manipulation of the bowel , inflammation , inhibitory neural reflexes , and endogenous and exogenous opioids . Alvimopan ( Entereg ) , approved by the FDA to accelerate upper and lower gastrointestinal ( GI ) recovery following partial large-bowel or small- bowel resection with primary anastomosis , represents a potential advance in the care of these patients . In five r and omized , double-blind , placebo-controlled , phase 3 clinical trials , alvimopan , compared with placebo , accelerated the time to GI recovery and hospital discharge status after bowel resection . In this article , we review the formulary details of alvimopan for in-hospital management of POI following this procedure Background : The current trend in postoperative nutrition is to promote a normal oral diet as early as possible . However , postoperative ileus is a frequent and common problem after major abdominal surgery . This study was design ed to investigate whether early enteral nutrition ( EEN ) , as a bridge to a normal diet , can reduce postoperative ileus . Methods : Patients undergoing major rectal surgery for locally advanced primary or recurrent rectal carcinoma ( after neoadjuvant (chemo)-radiation , with or without intraoperative radiotherapy ) were r and omly assigned to EEN ( n = 61 ) or early parenteral nutrition ( EPN , n = 62 ) in addition to an oral diet . Early nutrition was started 8 hours after surgery . Early parenteral nutrition was given as control nutrition to obtain caloric equivalence and minimize confounding . The primary endpoint was time to first defecation ; secondary outcomes were morbidity , other ileus symptoms , and length of hospital stay . Results : Baseline characteristics were similar for both groups . In intention-to-treat analysis , the time to first defecation was significantly shorter in the enteral nutrition arm than in the control arm ( P = 0.04 ) . Moreover , anastomotic leakage occurred significantly less frequently in the enteral group ( 1 patient ) compared with parenteral supplementation ( 9 patients , P = 0.009 ) . Mean length of stay in the enteral group was 13.4 ± 2.2 days versus 16.7 ± 2.3 days in the parenteral group ( P = 0.007 ) . Conclusions : Early enteral nutrition is safe and associated with significantly less ileus . Early enteral nutrition is associated with less anastomotic leakage in patients undergoing extensive rectal surgery Aim : Postoperative ileus is an important factor of complications following gastrointestinal procedures . Its pathophysiology and the parameters , which may impact on its duration , remain unclear . The aim of this study was to measure the role of various clinical determinants on restoration of intestinal function after  elective colorectal surgery .  Methods : From July 2002 to September 2003 , all patients who underwent laparotomy for colectomy ( laparoscopic resections excluded ) with either an ileotransverse , colocolic , or high colorectal anastomosis  were entered in this prospect i ve study . The intervals in hours between the end of the surgical procedure and passing of flatus ( PG ) and passing of stool ( PS ) were recorded by an independent investigator . PG and PS were eventually correlated with the following parameters : type of colectomy , early removal of nasogastric tube ( NGT ) , mechanical bowel preparation ( MBP ) , type of underlying disease , systemic administration of opiates , and surgical training ( colorectal fellowship or other ) . Results : One hundred twenty-four patients were entered in this study . Four patients ( 3.2 % ) developed septic complications ( 3 anastomotic leaks and 1 intraabdominal abscess ) and were excluded from the analysis . Median age in this population was 68 ( range 30–95 ) years .  Mean duration of postoperative ileus was 70±28 h ( PG ) and 99±34 h ( PS ) . The type of colectomy , underlying disease , MBP , and early NGT removal failed , in univariate analysis , to correlate with the duration of postoperative ileus . By contrast , time intervals PG and PS were statistically shorter in the group of patients treated by a colorectal surgeon [ 56±23 vs 74±28 h ( PG ) ; 82±26 vs 103±35 h ( PS ) , p=0.004 ] , as well as in patients who received systemic opiates for less than 2 days [ 64±27 vs 75±28 h ( PG ) , p=0.04 ; 88±32 vs 108±33 h ( PS ) , p=001 ] . Conclusion : Restoration of normal intestinal function after elective open colectomy takes 3 ( PG ) to 4 ( PS ) days . In our series , specialized training in colorectal surgery has a positive impact on the duration of postoperative ileus . Surgical specialization should be considered an important parameter in future clinical trials aim ing to minimize postoperative ileus Objective To compare early feeding with traditional postoperative dietary management for development of postoperative gastrointestinal symptoms , including ileus after major gynecologic surgery for benign conditions . Methods Women who had major gynecologic surgery for benign conditions were r and omly allocated to early feeding of low residue diets 6 hours postoperatively or traditional dietary management of clear liquids with normal bowel sounds , and regular diet with passage of flatus . Demographic and perioperative data were collected , and patients answered question naires on their perception of bowel function and pain using the McGill Pain Scale . Power analysis found that 130 women were needed to find a twofold greater incidence of ileus in the early feeding group with 80 % power and & agr ; = .05 . Results Complete data were available for 139 women , 67 allocated to the early feeding group and 72 to the late feeding group . The incidence of postoperative ileus for the study population was 4.4 % and did not differ between groups ( early 3 % versus late 5.8 % , P = .68 ) . There were no differences in patient demographics , surgical procedures , anesthesia used , and intraoperative complications between groups . With the exception of more complaints of nausea in the late feeding group ( 23 % versus 13 % , P = .04 ) , there were no differences in other postoperative variables , including other perioperative complications , pain medicine requirements , fluid and caloric intake , median pain scores , and gastrointestinal function . The low incidence of perioperative complications made the power to detect differences between groups low . Conclusion Low residue diet 6 hours after major gynecologic surgery for benign indications was not associated with increased postoperative gastrointestinal complaints , including ileus 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 protocol s , 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 central ly mediated analgesic effect . Several large r and omized 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 BACKGROUND & AIMS The evidence in support of Early Enteral Nutrition ( EEN )  after upper gastrointestinal surgery is inconclusive . The aim of this study was to determine if EEN improved clinical outcomes and shortened length of hospital stay . METHODS Open , prospect i ve multicentre r and omised controlled trial within a regional UK Cancer Network . One hundred and twenty-one patients with suspected operable upper gastrointestinal cancer ( 54 oesophageal , 38 gastric , 29 pancreatic ) were studied . Patients were r and omised to receive EEN ( n = 64 ) or Control management postoperatively ( nil by mouth and IV fluid , n = 57 ) . Analysis was based on intention-to-treat and the primary outcome measure was length of hospital stay . RESULTS Operative morbidity was less common after EEN ( 32.8 % ) than Control management ( 50.9 % , p = 0.044 ) , due to fewer wound infections ( p = 0.017 ) , chest infections ( p = 0.036 ) and anastomotic leaks ( p = 0.055 ) . Median length of hospital stay was 16 days ( IQ = 9 ) after EEN compared with 19 ( IQ = 11 ) days after Control management ( p = 0.023 ) . CONCLUSIONS EEN was associated with significantly shortened length of hospital stay and improved clinical outcomes . These findings reinforce the potential benefit of early oral nutrition in principle and as championed within enhanced recovery after surgery programmes , and such strategies deserve further research in the arena of upper GI surgery PURPOSE Postoperative ileus presents significant clinical challenges that potentially prolong hospital stay , contribute to readmission , and increase morbidity . There is no approved treatment for postoperative ileus . Alvimopan is a novel , peripherally acting , mu opioid receptor antagonist currently in development for the management of postoperative ileus . METHODS Patients undergoing partial colectomy or simple or radical hysterectomy were r and omized to receive alvimopan 6 mg ( n = 152 ) , alvimopan 12 mg ( n = 146 ) , or placebo ( n = 153 ) orally 2 hours before surgery and twice daily thereafter until discharge or for up to seven days . The primary efficacy end point , time to return of gastrointestinal function , was a composite measure of passage of flatus or stool and tolerating solid food . Secondary end points included time to the hospital discharge order written . Adverse events were monitored throughout the study . RESULTS Mean time to gastrointestinal recovery was significantly reduced in patients treated with alvimopan 6 mg vs. placebo ( hazard ratio = 1.45 ; P = 0.003 ) , with a smaller reduction seen with alvimopan 12 mg ( hazard ratio = 1.28 ; P = 0.059 ) . Mean time to the hospital discharge order written was significantly accelerated in patients treated with alvimopan 6 mg ( hazard ratio = 1.50 ; P < 0.001 ) . The most common treatment-emergent adverse events across all treatment groups were nausea , vomiting , and hypotension ; the incidence of nausea and vomiting was reduced by 53 percent in the alvimopan 12-mg group . CONCLUSIONS In patients undergoing major abdominal surgery , alvimopan accelerated gastrointestinal recovery and time to the hospital discharge order written compared with placebo and was well tolerated Background : Inadequate perioperative fluid therapy impairs gastrointestinal function . Studies primarily evaluating the impact of goal -directed fluid therapy on primary postoperative ileus are missing . The objective of this study was to determine whether goal -directed fluid therapy reduces the incidence of primary postoperative ileus after laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program . Methods : R and omized patient and assessor-blind controlled trial conducted in adult patients undergoing laparoscopic colorectal surgery within an Enhanced Recovery After Surgery program . Patients were assigned r and omly to receive intraoperative goal -directed fluid therapy ( goal -directed fluid therapy group ) or fluid therapy based on traditional principles ( control group ) .  Primary postoperative ileus was the primary outcome . Results : One hundred twenty-eight patients were included and analyzed ( goal -directed fluid therapy group : n = 64 ; control group : n = 64 ) . The incidence of primary postoperative ileus was 22 % in the goal -directed fluid therapy and 22 % in the control group ( relative risk , 1 ; 95 % CI , 0.5 to 1.9 ; P = 1.00 ) . Intraoperatively , patients in the goal -directed fluid therapy group received less intravenous fluids ( mainly less crystalloids ) but a greater volume of colloids . The increase of stroke volume and cardiac output was more pronounced and sustained in the goal -directed fluid therapy group . Length of hospital stay , 30-day postoperative morbidity , and mortality were not different . Conclusions : Intraoperative goal -directed fluid therapy compared with fluid therapy based on traditional principles does not reduce primary postoperative ileus in patients undergoing laparoscopic colorectal surgery in the context of an Enhanced Recovery After Surgery program . Its previously demonstrated benefits might have been offset by advancements in perioperative care BACKGROUND Postoperative ileus , a transient impairment of gastrointestinal motility , is a common cause of delay in return to normal bowel function after abdominal surgery .  Colectomy surgery patients who develop postoperative ileus could have greater health care re source utilization , including prolonged hospitalization , compared with those who do not develop postoperative ileus . Very few studies have assessed the impact of postoperative ileus on re source utilization and costs using retrospective analysis of administrative data bases . OBJECTIVE To assess health care utilization and costs in  colectomy surgery patients who developed postoperative ileus versus those who did not . METHODS A retrospective cohort study design was used . Adult patients with a principal procedure code for colectomy ( ICD-9-CM procedure codes 45.71 - 45.79 ) , discharged between January 1 , 2004 , and December 31 , 2004 , were identified from the Premier Perspective data base of inpatient records from more than 500 hospitals in the United States . The colectomy patients were further classified for the presence of postoperative ileus , identified by the presence , in any diagnosis field on the administrative patient records , of a code for paralytic ileus ( ICD-9-CM code 560.1 ) and /or digestive system complications ( ICD-9-CM code 997.4 ) during the inpatient stay . Code 997.4 was used to account for cases in which postoperative ileus would be reported as a complication of anastomosis , as could be the case in colectomy surgeries . Hospital length of stay ( LOS ) and hospitalization costs were compared using t-tests . Multivariate analyses were performed with log-transformed LOS and log-transformed cost as the dependent variables . Patient demographics , mortality risk , disease severity , admission source , payment type ( retrospective/ prospect i ve ) , and hospital characteristics were used as covariates . RESULTS A total of 17,876 patients with primary procedure code for colectomy were identified , of whom 3115 ( 17.4 % ) patients were classified for presence of postoperative ileus ( including paralytic ileus only [ n=1216 ; 6.8 % ] , digestive system complications only [ n=383 ; 2.1 % ] , or both [ n=1516 ; 8.5 % ] ) . A majority of the colectomy patients with and without postoperative ileus , respectively , were male ( 54.1 % vs. 50.3 % , P < 0.001 ) , Caucasian ( 70.5 % vs. 69.3 % , P = 0.170 ) , and aged 51 - 64 years ( 51.1 % vs. 49.7 % , P = 0.143 ) . The mean [ SD ] hospital LOS was significantly longer in patients with postoperative ileus ( 13.8 [ 13.3 ] days ) compared with patients without postoperative ileus ( 8.9 [ 9.5 ] days ; P < 0.001 ) . Presence of postoperative ileus was found to be a significant predictor of LOS ( P < 0.001 ) in the regression model , controlling for covariates . Female gender ( P = 0.002 ) , greater severity level ( P < 0.001 ) , and hospital bed size of more than 500 ( P = 0.013 ) were other significant predictors of hospital LOS . Presence of postoperative ileus was found to be a significant predictor of hospitalization costs ( P < 0.001 ) , controlling for covariates . CONCLUSION  Postoperative ileus in  colectomy patients is a significant predictor of hospital re source utilization Background Postoperative ileus is common after surgery . One non-pharmacological intervention that has shown promising results in reducing the duration of postoperative ileus is chewing gum after surgery . However , this has not been investigated in upper gastrointestinal surgery such as pancreatic surgery . Hence the aim of this study was to investigate the effects of chewing gum treatment on patients undergoing pancreaticoduodenectomy ad modum whipple due to pancreatic or periampullary cancer . Methods This study was conducted as a phase III trial that was terminated early . Patients diagnosed with pancreatic tumours scheduled for pancreaticoduodenectomy ad modum whipple were included . The treatment group received chewing gum postoperatively and st and ard care . Controls received glucose solution and st and ard care . Chewing gum and glucose were used four times a day during the whole hospital stay . Time to first flatus and stool was defined as the primary outcome . The secondary outcome was start with clear liquids , start with liquid diet and length of hospital stay . Results No statistically significant differences could be observed between the chewing gum intervention group and the control group . However , a numerical difference in mean time was observed in first flatus , first stool , start of clear fluids , and start of liquid diet and length of hospital stay in favour of the intervention group . Conclusions Although this study did not find statistically significant differences favouring the use of chewing gum for postoperative ileus , a positive trend was observed of a reduction of the impact of postoperative ileus among patients after pancreatic surgery . It also contributes valuable method ological experience that is important for future studies of chewing gum interventions during recovery after pancreatic surgery . Trial registration Clinical Trials.gov identifier : NCT02319512 , publication date 2014 - 12 - 17 Between August 1988 and September 1989 , 100 consecutive patients who underwent elective abdominal colorectal surgical procedures were prospect ively r and omized to receive or not to receive metoclopramide . Metoclopramide was intravenously administered every 8 hours from the completion of surgery until a solid food diet was able to be tolerated . Seven patients were not included in the final tabulations because of one death , one small bowel obstruction requiring laparotomy , one anastomotic leak requiring laparotomy , and four protocol violations . Ninety-three patients , 37 men and 56 women ( mean age , 59.5 ; range , 14–89 years ) underwent 40 segmental colectomies , 13 total abdominal colectomies , 8 abdominoperineal resections , 8 ileoanal pouch procedures , 7 small bowel resections , and 17 other colorectal procedures . The 40 patients who received postoperative metoclopramide were in Group 1 , and the 53 who did not were in Group 2 . The mean length of time between laparotomy and commencement of oral fluid and oral solid intake in Groups 1 and 2 were 3.5 and 4.8 days , and 3.5 and 5.0 days , respectively . These differences were not statistically significant ( P>0.05 ) . Prolonged ileus was seen in seven patients in Group 1 and in eight patients in Group 2 . These differences were also not statistically significant ( P>0.05 ) . Prolonged ileus was defined as the need for nasogastric tube reinsertion or discontinuation of oral intake . We conclude that metoclopramide does not significantly alter the course of postoperative ileus Background : Postoperative ileus ( PI ) is the transient impairment of bowel motility due to surgical trauma and the associated physiological responses . Postoperative ileus results in patient discomfort , increases gastrointestinal risks , prolongs hospital stay and increases medical expenses . In this study , we investigated the effect of patient‐controlled analgesia ( PCA ) morphine with or without ketorolac on bowel functions in patients after colorectal surgeries OBJECTIVE To investigate the efficacy and safety of alvimopan , 12 mg , administered orally 30 to 90 minutes preoperatively and twice daily postoperatively in conjunction with a st and ardized accelerated postoperative care pathway for managing postoperative ileus after bowel resection . DESIGN , SETTING , AND PATIENTS This multicenter , r and omized , placebo-controlled , double-blind , phase 3 trial enrolled adult patients undergoing partial bowel resection with primary anastomosis by laparotomy and scheduled to receive intravenous , opioid-based , patient-controlled analgesia .  A st and ardized accelerated postoperative care pathway including early ambulation , oral feeding , and postoperative nasogastric tube removal was used to facilitate gastrointestinal ( GI ) tract recovery in all of the patients . MAIN OUTCOME MEASURES The primary end point was time to GI-2 recovery ( toleration of solid food and first bowel movement ) . Secondary end points included time to GI-3 recovery ( toleration of solid food and first flatus or bowel movement ) , hospital discharge order written , and actual hospital discharge . Postoperative length of hospital stay based on calendar day of hospital discharge order written , opioid consumption , and overall postoperative ileus-related morbidity were recorded . RESULTS Alvimopan , 12 mg , was well tolerated and significantly accelerated GI-2 recovery , GI-3 recovery , and actual hospital discharge compared with a st and ardized accelerated postoperative care pathway alone ( hazard ratio = 1.5 , 1.5 , and 1.4 , respectively ; P < .001 for all ) . Time to hospital discharge order written as measured by hazard ratio ( 1.4 ) and by postoperative calendar days ( mean for alvimopan , 5.2 days ; mean for placebo , 6.2 days ) was also accelerated . Opioid consumption was comparable between groups , and alvimopan was associated with reduced postoperative ileus-related morbidity compared with placebo . CONCLUSIONS Alvimopan , 12 mg , administered 30 to 90 minutes before and twice daily after bowel resection is well tolerated , accelerates GI tract recovery , and reduces postoperative ileus-related morbidity without compromising opioid analgesia Purpose Ileus is a common event following cesarean section . Early post-cesarean recovery is very important not only for the mother but also for the baby who is dependent on breastfeeding . This article aims to demonstrate the efficacy of metoclopramide for the prevention of ileus after cesarean . Methods In this r and omized controlled trial , 696 women scheduled for cesarean were r and omized in two groups . Three hundred fifty-three persons settled in control group and 343 were assigned in intervention group who received an injection of 10-mg intramuscular metoclopramide  prior to operation . After cesarean , the participants recorded the first flatus , defecation , feeling of hunger , feeding and ambulation in a question naire , and also their sense of bloating in a visual analog scale under supervision of a research assistant . The data was analyzed by SPSS 17 , t test , and chi-square , while p < 0.05 was considered significant . Results The interval between cesarean and the first flatus ( p < 0.0001 ) , defecation ( p < 0.0001 ) , feeling of hunger ( p < 0.0001 ) , feeding ( p = 0.007 ) , and ambulation ( p < 0.0001 ) were significantly shorter in the metoclopramide group . In addition , polytomous logistic regression analysis showed the metoclopramide group had less bloating with significant difference ( OR = 2.83 and CI 1.91–4.21 ) . Conclusions Our study proved the functionality of metoclopramide in preventing ileus . As this drug is safe , tolerable , harmless , inexpensive and available , and also no definite method has been developed to prevent ileus after cesarean ; yet , metoclopramide could be considered as a suitable option . Certainly with regard to some limitations in our study , further comprehensive studies are still required to ensure validity of the obtained results Since its introduction in the 1990s , the concept of multimodal perioperative care ( fast-track surgery , enhanced recovery programmes ) has gained widespread acceptance and is now considered as a st and ard of care . Most studies that support this approach relate to colorectal surgery , but similar data have been published across surgical specialties with major economic benefits 1–4 . The implementation process has been described in detail and is essentially based on the simple question : ‘ Why is the postoperative patient in hospital today?’1,5 . The relevant question may therefore be asked – what next ? Postoperative length of stay is often seen as the key outcome for fast-track surgery and , although this may not always be appropriate , whatever is used as a primary outcome measure must be justified adequately . It should also be emphasized that significant progress in fast-track care dem and s inclusion and implementation of all of its basic components . Many studies have not implemented the most important aspects of the care programmes that were originally described , including patient information , effective thoracic epidural analgesia with sufficient local anaesthetic that facilitates early mobilization , reduced ileus and rapid re introduction of oral feeding , or the use of non-opioid analgesia , where appropriate , in open or minimally invasive surgery . An important issue that needs to be addressed in future is detailed analysis of ‘ medical ’ versus ‘ surgical ’ morbidity6 . To improve further our underst and ing of perioperative risk , future studies must analyse how one specific complication might lead to another : for instance , whether a pneumonia or myocardial infa rct ion led to an anastomotic dehiscence ; or a wound dehiscence with reoperation led to a subsequent pneumonia , myocardial infa rct ion or thromboembolic complication6 . Initial ‘ medical ’ morbidity may depend on perioperative care principles and pre-existing comorbidity , in contrast to an initial ‘ surgical ’ complication , which may depend on surgical technique , and therefore require a different approach from fast-track methodology . How might the fast-track approach evolve further , as surgeons perform an ever-increasing number of major procedures in older patients with comorbidities , with greater risks of postoperative complications , prolonged hospital stay and death6 ? Preoperative evaluation of operative risk may not be helpful unless evidence -based perioperative interventions are available and instituted . Thus , the specific role of preoperative morbidity , such as smoking , diabetes and cardiopulmonary disease , in determining the risk of postoperative morbidity needs to be reassessed in studies with a fully implemented fast-track procedure-specific programme6 . We also need to have a second look at the relative roles of the different components of the fast-track programme ( for example type of analgesia and fluid management1,5 ) and analyse where progress can be made in order to reduce perioperative risk and morbidity , instead of focusing on length of stay as the primary outcome . The surgical stress response is proportional to the degree of insult and the main factor that contributes to postoperative organ dysfunction1,2 . Every effort should therefore be made to reduce those responses that are undesirable . Regional anaesthetic techniques have a powerful effect on the catabolic response , reducing cardiac dem and s , pain , pulmonary dysfunction and ileus .  Regional anaesthesia should be used whenever possible on a procedure-specific basis7 . Inflammatory responses contribute to pain , fatigue and organ dysfunction . They can be modified pharmacologically by preoperative glucocorticoids8 . Significant reductions in pain , nausea and vomiting , and early fatigue have been demonstrated , facilitating early recovery , so far without demonstrable side-effects . More procedure-specific and dosefinding studies are required . A single preoperative glucocorticoid dose in a larger amount than used for conventional nausea and vomiting prophylaxis might , for instance , be an important contributory factor to improving fast-track programmes in high-risk patients . Minimally invasive surgery also reduces the inflammatory response , although the contribution that this plays in the context of fast-track programmes in colonic surgery is difficult to interpret , as the care programmes used in the ‘ open ’ groups have often not been fully implemented6,9,10 . Therefore , future efforts to assess early postoperative outcome effects of minimally invasive surgery should include r and omized studies with fully implemented fasttrack programmes11 . Newer developments in minimally invasive PURPOSE This study investigated the impact of early enteral nutrition ( EEN ) on the clinical outcomes of gastric cancer patients after radical gastrectomy . METHODS Four hundred gastric cancer patients undergoing radical gastrectomy of any extend with D2 nodal dissection were r and omly divided into an experimental and a control group with 200 cases in each group . Patients in the control group received postoperative parenteral nutrition ( PN ) , while patients in the experimental group received postoperative EEN . After treatment , the clinical outcomes , postoperative immune function , and nutritional status of the two groups were evaluated . RESULTS The postoperative fever time , intestinal function recovery time , anal exhaust time , and the length of hospital stay for patients in the experimental group were significantly shorter than those of the control group . We did not find significant differences in anastomotic leak , postoperative ileus and regurgitation between the two groups . The activities of multiple immune cell types , including CD3⁺ , CD4⁺ , CD4⁺/CD8⁺ , and natural killer ( NK ) cells , were significantly lower in both groups on postoperative day 1 when compared with the preoperative levels ( p<0.05 ) . The level of CD8⁺ was not significantly different between the two groups ( p>0.05 ) . After treatment , levels of CD3⁺ , CD4⁺ , CD4⁺/CD8⁺ , and NK cells in the experimental group patients were 35.6 ± 4.2 , 42.2 ± 3.0 , 1.7 ± 0.3 , and 27.3 ± 5.3 % , respectively , on postoperative day 7 , which were similar to the preoperative levels . The immune cell levels from the control group patients remained significantly lower when compared with preoperative values ; in addition , these values were also significantly lower when compared with the EEN patients ( p<0.05 ) CONCLUSION : For gastric cancer patients undergoing radical gastrectomy , the clinical outcome , immune function and nutritional status  after EEN were significantly improved . These data suggest the widespread use of EEN in clinical practice OBJECTIVE To investigate the feasibility of a 48-hour postoperative stay program after colonic resection . SUMMARY BACKGROUND DATA Postoperative hospital stay after colonic resection is usually 6 to 12 days , with a complication rate of 10 % to 20 % . Limiting factors for early recovery include stress-induced organ dysfunction , paralytic ileus , pain , and fatigue . It has been hypothesized that an accelerated multimodal rehabilitation program with optimal pain relief , stress reduction with regional anesthesia , early enteral nutrition , and early mobilization may enhance recovery and reduce the complication rate . METHODS Sixty consecutive patients undergoing elective colonic resection  were prospect ively studied using a well-defined postoperative care program including continuous thoracic epidural analgesia and enforced early mobilization and enteral nutrition , and a planned 48-hour postoperative hospital stay . Postoperative follow-up was scheduled at 8 and 30 days . RESULTS Median age was 74 years , with 20 patients in ASA group III-IV . Normal gastrointestinal function ( defecation ) occurred within 48 hours in 57 patients , and the median hospital stay was 2 days , with 32 patients staying 2 days after surgery . There were no cardiopulmonary complications . The readmission rate was 15 % , including two patients with anastomotic dehiscence ( one treated conservatively , one with colostomy ) ; other readmissions required only short-term observation . CONCLUSION A multimodal rehabilitation program may significantly reduce the postoperative hospital stay in high-risk patients undergoing colonic resection . Such a program may also reduce postoperative ileus and cardiopulmonary complications . These results may have important implication s for the care of patients after colonic surgery and in the future assessment of open versus laparoscopic colonic resection Background / Objective : Postoperative ileus ( POI ) after colorectal surgery is associated with prolonged hospital stay and increased costs . The aim of this study is to investigate pre- , intra- , and postoperative risk factors associated with the development of POI in patients undergoing laparoscopic partial colectomy .  Methods : Patients operated between 2004 and 2008 were retrospectively identified from a prospect ively maintained data base , and clinical , metabolic , and pharmacologic data were obtained . Postoperative ileus was defined as the absence of bowel function for 5 or more days or the need for reinsertion of a nasogastric tube after starting oral diet in the absence of mechanical obstruction . Associations between likelihood of POI and study variables were assessed univariably by using & khgr;2 tests , Fisher exact tests , and logistic regression models . A scoring system for prediction of POI was constructed by using a multivariable logistic regression model based on forward stepwise selection of preoperative factors . Results : A total of 413 patients ( mean age , 58 years ; 53.5 % women ) were included , and 42 ( 10.2 % ) of them developed POI . Preoperative albumin , postoperative deep-vein thrombosis , and electrolyte levels were associated with POI . Age , previous abdominal surgery , and chronic preoperative use of narcotics were independently correlated with POI on multivariate analysis , which allowed the creation of a predictive score . Patients with a score of 2 or higher had an 18.3 % risk of POI ( P < 0.001 ) . Conclusion : Postoperative ileus after laparoscopic partial colectomy is associated with specific preoperative and postoperative factors . The likelihood of POI can be predicted by using a preoperative scoring system . Addressing the postoperative factors may be expected to reduce the incidence of this common complication in high-risk patients STUDY OBJECTIVE To assess the efficacy of metoclopramide for treatment of postoperative ileus in patients who underwent exploratory laparatomy .  DESIGN Prospect i ve observational study SETTING Surgical intensive care unit ( SICU ) . PATIENTS Thirty-two patients who underwent exploratory laparatomy INTERVENTION Sixteen patients received metoclopramide  , and 16 did not . The primary outcome was time to first postoperative bowel movement . Secondary end points were length of stay ( LOS ) in the SICU and total hospital LOS . MEASUREMENTS AND MAIN RESULTS The mean number of days to first bowel movement was nearly identical for both the treatment group and control group ( 4.8 vs 4.7 days , respectively , p=0.93 ) . Length of stay in the SICU was 8.3 days for the treatment group and 8.6 days for the control group ( p=0.89 ) , and total LOS was 18.0 and 20.1 days , respectively ( p=0.63 ) . CONCLUSION The time to first bowel movement was not significantly different between the treatment and control groups . Also , metoclopramide did not decrease LOS .  Metoclopramide does not have a role in the treatment of postoperative ileus Postoperative convalescence is mainly determined by the extent and duration of postoperative ileus . This r and omized clinical trial evaluated the effects of  early oral feeding  on functional gastrointestinal recovery and quality of life Metoclopramide or placebo was administered postoperativcly in a r and omized , double-blind fashion to 115 patients undergoing laparotomy . The effect of metoclopramide on postoperative adynamic ileus ( PAI ) was evaluated . The patients were stratified into two groups : Group A — those with laparotomy without a gastrointestinal anastomosis or ostomy procedure , and group B — those with laparotomy undergoing an anastomosis or ostomy procedure . Metoclopramide reduced nausea and emesis postoperatively . However , the only significant effect on postoperative adynamic ileus was an earlier return to tolerance of solid foods in the patients in Group AIM This study aim ed to determine the effect of gum chewing on the reduction of postoperative ileus and recovery after surgery . METHODS This study was conducted a r and omized controlled trial in 60 patients who underwent colorectal surgery between November 2011 and December 2012 . Patients in the experimental group chewed gum three times a day . The time of flatus and defecation , the time to start feeding , pain levels and time of discharge were monitored . RESULTS Post-surgery results for gum-chewing were first flatus and defecation times and the time to start feeding was shorter ; pain levels were lower on the 3rd - 5th days ; patients were discharged in a shorter time post-surgery . CONCLUSIONS Chewing gum is a simple intervention for reducing postoperative ileus after colorectal surgery . Further studies that examine the effectiveness of gum chewing on other surgical interventions in which the development risk of postoperative ileus should be performed PURPOSE Cardiovascular optimization via esophageal Doppler can minimize gastrointestinal hypoperfusion , reducing the risk of multiple organ dysfunction and postoperative complications during major surgery . We assessed the effect of esophageal Doppler guided cardiovascular optimization in patients undergoing radical cystectomy . MATERIAL S AND METHODS We conducted a prospect i ve , r and omized , double-blind controlled trial at a United Kingdom teaching hospital between 2006 and 2009 . A total of 66 patients were r and omized to a control arm ( 34 ) and an intervention arm ( 32 ) . The control group received st and ard intraoperative fluids . The intervention group received ( additional ) Doppler guided fluid . Primary outcomes were markers of gastrointestinal morbidity such as ileus , flatus and bowel opening . Secondary outcomes were postoperative nausea and vomiting , wound infection and operative intravenous fluid volumes ( total and hourly ) . RESULTS There were significant reductions in the control and intervention arms in the incidence of ileus ( 18 vs 7 , p < 0.001 ) , flatus ( 5.36 vs 3.55 days , p < 0.01 ) and bowel opening ( 9.79 vs 6.53 days , p = 0.02 ) , respectively . Nausea and vomiting were significantly reduced in the study group at 24 and 48 hours postoperatively ( 11 vs 3 , p < 0.01 and 13 vs 1 , p < 0.0001 ) . Wound infection rates were significantly reduced ( 8 vs 1 superficial , p < 0.01 and 10 vs 2 combined , p < 0.01 ) . Study patients received significantly higher volumes ( ml/kg per minute ) of intravenous fluid ( 0.19 vs 0.23 , p < 0.01 ) related to a significantly higher volume ( ml/kg ) in the first hour of surgery ( 14.1 vs 21.0 , p = 0.0001 ) . CONCLUSIONS Cardiovascular optimization using esophageal Doppler significantly improved postoperative markers of gastrointestinal function
Neither metoclopramide nor erythromycin were effective in expediting the resolution of ileus .
Analyses of 32 r and omized controlled trials showed that EEN facilitates return of normal bowel function , achieving enteral nutrition goals , and reducing hospital length of stay .
CONCLUSION In patients who have undergone abdominal surgery , we strongly recommend EEN to expedite resolution of Ileus , but we can not recommend for or against the use of either metoclopramide or erythromycin to hasten the resolution of ileus in these patients .
BACKGROUND Ileus is a common challenge in adult surgical patients with estimated incidence to be 17 % to 80 % .
The main mechanisms of the postoperative ileus pathophysiology are fluid overload , exogenous opioids , neurohormonal dysfunction , gastrointestinal stretch , and inflammation .
Management includes addressing the underlying cause and supportive care .
Multiple medical interventions have been proposed , but effectiveness is uncertain .
A working group of the Eastern Association for the Surgery of Trauma aim ed to evaluate the effectiveness of metoclopramide , erythromycin , and early enteral nutrition ( EEN ) on ileus in adult surgical patients and to develop recommendations applicable in a daily clinical practice .